Transcription:
Beyond the Baby Blues: Perinatal Mood and Anxiety Disorders

Caitlin Whyte: As a new parent, people expect you to be happy, joyful, and glowing after you have your baby. But maybe you're not. Maybe you're crying a lot or you're nervous or easily angered. You are not alone in these feelings. Joining us for this important conversation on perinatal mood and anxiety disorders is Christine Kowaleski. She is a psychiatric nurse practitioner certified in family, neonatal and psychiatric care. She also serves as the co-chair for the New York chapter of Postpartum Support International.

Welcome to Crouse HealthCast, a podcast brought to you by Crouse Health. I'm Caitlin Whyte. So Christine, to start us out, describe what perinatal mood and anxiety disorders are and who is affected by them.

Christine Kowaleski, DNP, MHNP-BC: Well, perinatal mood and anxiety disorders encompasses a vast array of emotional symptoms that a mother or her partner may experience during or after a pregnancy. And what happens with the birth mother is there are actual physical brain changes. So there's a small complex organ at the base of the brain called the amygdala. During pregnancy, the amygdala enlarges and studies using structural magnetic resonance or MRIs have demonstrated that this increase in size actually does happen and it's associated with major depressive disorder. That's also the flight or fight response area. It's responsible for emotions. And when that fight or flight and fear center is activated, it can cause someone to be overprotective. I think in some ways maybe it's nature's way of saying, "Oh, you're having a baby, so now you need to be a little afraid and protect your baby." But when these moms go without sleep, then it's a whole 'nother story. This, you know, sleep is torture, right? We torture prisoners by not letting them sleep. So any change in the mother's emotional status, and it can be as simple as the fact that she's crying all day or doesn't feel connected to the baby. Some moms are depressed. Some moms are anxious when we do screenings on them, they usually fall in an area where the anxiety and the depression are pretty equal. So they're very common. And we'll talk more about that.

But who is affected is a very tricky question. In most cases, with appropriate screening during pregnancy and early postpartum, we can identify moms at risk. Yet there's still sometimes a person that pops up with significant symptoms after all her screenings were negative. So the best way for us to identify is to make clear to the mother that there's no judgment because often moms are so afraid if they tell the truth in these screenings that they'll lose their babies. So that's key. And then we believe in screening, screening, screening. So our recommendation is to screen moms frequently during pregnancy and then postpartum.

Another group that seems to be affected more than previous moms are the millennials. They seem to have a higher incidence of adjustment disorder and it really makes sense. They come from smaller families, they have less sharing as a child. They're encouraged to succeed academically and their careers. And they were told that they could have it all. And we did that to them. We told them that. I told my daughters that, and now I'm kind of biting my tongue. And many of them put childbearing off. So now, you're talking about possibly infertility problems. And they've had all of these years, adult years with their partner where they had control of their lives. And then this little, you know, six to eight-pound child arrives and that child's in charge. You know, they are out of control, the child is all the control. And grandparents are older when the moms are waiting to have babies and they live further away and don't have the support systems they had for generations past.

We've talked a lot in my profession about what's called a fourth trimester, which is impossible, right? You can't have four trimesters. But it's thought that if the obstetrician could see the mother more frequently during the three months postpartum, that we would see less a morbidity from the postpartum depression.

Caitlin Whyte: So why is maternal depression and anxiety considered the number one complication of pregnancy?

Christine Kowaleski, DNP, MHNP-BC: So statistics show that one out of seven to one out of five, so 14% to 20% of women experience a perinatal mood and anxiety disorder. And that's not including those who do not come forward. Other things that are tracked much more closely is gestational diabetes. And that's only 2% to 10% of the moms and hypertension is only 6% to 8% of the moms. So, you know, we're always focused on these physical, and I'm not saying that we shouldn't be, we should definitely, those are very important to watch those, however, the mother's mental state is just as important.

Actually in 2005, there was an article that talked about suicide. It was Lindahl and colleagues and it was published in 2005 and they were stating that suicide was found to be the second or leading cause of death in this depressed population. And our country has not gotten better over the years because in Psychiatric Times in 2020, Leah Kuntz writes that suicide attempts among pregnant or postpartum mothers have nearly tripled over the past decade. So part of it is that there was no tracking. A woman would die during the first postpartum year, but they weren't tracking if she had a baby before that. So now, they are doing that. When a woman commits suicide during the first postpartum year, it is tracked and now they have better statistics.

Caitlin Whyte: So, can you talk about some of those warning signs or symptoms that you see in women or their loved ones that we can watch out for during and after pregnancy?

Christine Kowaleski, DNP, MHNP-BC: Yeah, sure. So there's a couple of publications that the NIH put out and it really is helpful for families to get these. We have them in most of our obstetrician offices. But the partner can look for signs like does she seem to get extremely anxious, sad, or angry without warning? And anger is one of the things that might present initially. And the significant other will be the first one that sees that. She may feel foggy, trouble concentrating, completing tasks, doesn't have the interests that she had in things that she used to enjoy and seems robotic, like she's just going through the motions, you know, to complete a task, maybe having trouble sleeping. Checks things repeatedly, is having trouble caring for herself and the baby. This can all be broken down into the acuity. So which things are worrisome and which things are not. And I think later on, we're going to talk about the baby blues a little bit. Is that right?

Caitlin Whyte: Actually, that's my next question. Can you tell us about that difference between the baby blues and postpartum depression? Which is which?

Christine Kowaleski, DNP, MHNP-BC: So when a mother is pregnant, her hormones, I say they climb up. And by the time she delivers, they are up in the penthouse, right? And they cut the cord and they immediately fly down on the fastest elevator to the basement. That hormone change is responsible for the baby blues. So moms will be a little weepy. The interesting thing about the baby blues is they're gone by three weeks postpartum. So that's a key thing to remember for families, is if mom is more than three weeks postpartum, it is not the baby blues anymore. And women who have the baby blues may go into experience postpartum depression and anxiety. But once when you see postpartum depression and anxiety, you're going back to that intense anxiety that hits with no warning, the fogginess, the robotic feeling, anxious around the baby, has scary and upsetting thoughts that don't go away, feeling guilty, like she's not a good mom. And the scary thoughts are another key factor. So it's very common that it's associated with falling down the stairs, driving a car into a lake, baby hitting head going through a doorway. Those are some of the common fears that the mother has, like she's going to fall down the stairs. And a lot of our patients will say, "I can't take the baby down the stairs. I have to have my significant other do it." So that's postpartum depression.

And then, there's major depressive disorder and sometimes leads to postpartum psychosis and that is complete hopelessness and total despair. She feels out of touch with reality. She might see or hear things that other people don't. And she feels like she might hurt herself or her baby. And the National Institute of Health has put out on their website an action plan for depression and anxiety around pregnancy. I love this. I give it to every mother. When you look at it, the colors are analogous with a traffic light. So baby blues are in green, postpartum depression's in yellow and the severe hopelessness, total despair and so on means get help, now that's in red. So that's a great resource for all families.

Caitlin Whyte: Now, I understand Crouse's Kienzle Family Maternity Center also screens for postpartum depression during a new mother's stay in the hospital. Tell us about that.

Christine Kowaleski, DNP, MHNP-BC: There's a lot of controversy about this as far as whether or not should we screen in hospitals. Reason being, we just told you that the baby blues go away at three weeks. So a mother may be experiencing the baby blues and have a positive screen on her screening evaluation. So day one or two, because moms don't stay more than that usually, is not an optimal time for screening. However, if a woman screens positive on her screen in the hospital, we alert the obstetrician about that so that the obstetrician can see the mother sooner than six weeks and give the mother another screening. So this has actually allowed us to capture mothers much earlier in their course of postpartum depression and treat them much earlier and then they have less sequelae from their disease.

Caitlin Whyte: So then what types of treatment can women who experience these feelings expect?

Christine Kowaleski, DNP, MHNP-BC: Well, there's many different therapy modalities, anything from integrative medicine to prescription therapies. I always say to the moms, "Part of your treatment plan is probably going to one of our support groups," because that will give them a feeling that they're not alone and mothers, you know, have gone through what they went through and now are feeling better, that instills a sense of hope in the new mom. There's been studies about massage. If you can afford to have a massage three times a week, it could make you feel as good as having an antidepressant, and I think I should volunteer for that.

But, we do truly believe that it's not just an all one approach. So with our program, we see moms very early. So in a general psychiatry, if you want to get into a psych nurse practitioner, you would wait maybe months to get in, and that's too long for our clients. So we have two right now certified nurse practitioners that see patients Monday through Friday, and we do an entire screening. There's six screening tools that the mother has to complete the day before we meet. And we usually see them within a week of their calling us. And we go through those screening tools and it really helps us fare it out if this mom has bipolar, if she truly has just straight up postpartum depression and anxiety, or if she has maybe a personality disorder. But if we don't do those screening tools, if we don't do those, then we might not treat her right. And that's why it's so very important for someone who's having emotional struggles postpartum, that she come to a practice like ours to get the appropriate screening because general practitioners do not get that much training in psychiatry. And they just initially, and I'm not saying it's bad, I probably couldn't do their job; however, the first thing that gets handed out is an antidepressant. Well, if a mother's got bipolar, she could go into a manic stage. So they really need all of these screening tools. That's what they can expect when they come to us. I think we're very approachable, both myself and the other clinician. And, you know, we love our moms.

Caitlin Whyte: Well, you mentioned the Crouse Family Support Group. Can you tell us about how often it meets and if there's a cost?

Christine Kowaleski, DNP, MHNP-BC: Yeah. So the support group meets twice a week. It meets Tuesday evenings at 6:00 PM and Fridays at noon. This is free for anyone regardless of where the mother delivers, where she lives. She doesn't even have to live in New York state. We do say though, parents of premature infants, they are offered a support group through Postpartum Support International and can see our providers for individual treatment. But our general support group would not be appropriate for those moms.

Caitlin Whyte: Can you describe what a new mom attending one of these support groups, what should they expect in the meeting?

Christine Kowaleski, DNP, MHNP-BC: Well, initially, we have two facilitators in the meeting. Sometimes it's a nurse practitioner and an OB nurse. Sometimes it's two nurses and we tell them, "Here's kind of the ground rules for our group." One is that what's said in the group stays in the group. We explain that it's a peer support group, not a therapy group. And we try to explain that everybody needs an opportunity to talk, so, you know, be respectful of their time. So we go through the ground rules. And the first thing we say though is that there's no judgment here. And if you might've come into the group and you just want to sit and listen, that's fine. You don't even have to turn your camera on. So whatever makes you comfortable is fine with us. Usually, the moms who have been in the group for awhile will start out and they'll talk about their experience. And it kind of goes around in a circle. Usually, the moms who are most afraid of going are the ones that enjoy it the most. So I think it's a great treatment for them. Sometimes I say, "Those moms can help you more than I can. I can give you medications, but you need to hear from other moms that you're not alone. You're not alone. This is not your fault. And you will get better with help.

Caitlin Whyte: And what about dads or partners of women who are experiencing PMAD, is there support for them?

Christine Kowaleski, DNP, MHNP-BC: We will see them individually for treatment, for medicinal treatment. They are invited to the support groups as well, and many have attended. They usually come with their wife or a partner. And it is true that they say 20% of women will have postpartum depression and 10% of dads or partners will also experience a perinatal mood and anxiety disorder. They don't have that drop in hormones, but there is thoughts that the hormones do change. Their issues are often different because they have to share their wife, there's the responsibility of caring for a new baby. We do certainly invite them and welcome them. We don't have a specific support group for significant others. However, Postpartum Support International does have that group on their website.

So the FDA approved a new drug. It's the only drug that technically has been created for perinatal mood and anxiety disorders. It's called Brexanolone and it's given through an IV. And we were the first hospital in New York state to administer this and we had a wonderful response with it. Unfortunately, hospital beds have been filled with COVID. So we haven't had the opportunity to be able to administer that, but I'm hoping that turns around again for us as the COVID wave goes away.

Caitlin Whyte: Well, Christine, wrapping up here, are there any other resources you want people to know about? Anything we didn't touch on that you'd like to add?

Christine Kowaleski, DNP, MHNP-BC: I could give you a long, long list of support places for moms to look. I really have to say the best place and the most inclusive place that will have all of the resources is Postpartum Support International and it's postpartum.net. So that's very simple. It has accurate information. It has I don't even know how many support groups, maybe 20. It'll give them information on where to go for help if they live in another state. They can actually go to their state and see who offers treatment for them. 2020 Mom is another good site for good information, but not nearly as inclusive as PSI. And then always the National Institute of Health, Maternal Mental Health is a good website for them to go to.

Caitlin Whyte: Well, Christine, this is just some critical information to keep in mind for the new parents in our lives. Thank you so much for sharing. Visit crouse.org/familysupport or call (315) 470-7940 for a one-on-one session. That's (315) 470-7940. If you found this podcast helpful, please do share it on social media. This is Crouse HealthCast, a podcast brought to you by Crouse Health. I'm Caitlyn Whyte. Be well.