Warner Huh, MD (Host): Hello everyone, this is Dr. Warner Huh, the Chair of Obstetrics and Gynecology at the University of Alabama at Birmingham. I'd like to wish you all a Happy New Year, Happy 2025. I know that we've taken a little bit of a break from these monthly podcasts, but super excited to kick off a series of excellent podcasts for 2025.

This monthly episode for Women's Health with Dr. Huh is on the topic of perinatal mental health. So uniquely we're going to do this in two parts because personally I think the content is so important, particularly for the general public and the community. But before we get into the podcast, I'd like to welcome two guests who are going to participate with us today is Dr. Rachel Fargason, who is the Patrick H. Linton Professor, as well as the Medical Quality Officer and Senior Associate Director of Strategic Planning in the Department of Psychiatry at UAB, and she has a very specific interest in perinatal mental health, as well as one of our awesome nurse practitioners, Katy Orr, who is in the department of OBGYN here at UAB and also has a very specific interest in perinatal mental health. So, Dr. Fargason and Ms. Orr, welcome to the podcast today.

Rachel Fargason, MD: Thank you.

Katy Orr, CRNP: Thank you so much.

Host: Can you just tell the listeners a little bit about what is perinatal mental health? Some of our listeners may not know exactly what we're talking about, but further, why is this topic particularly important?

Katy Orr, CRNP: Perinatal mental health is similar to mental health in regular adulthood, but it affects women who are in the what we call perinatal phase of life, and that includes women who are currently pregnant or postpartum. It also can include women who have suffered a pregnancy loss or are walking through infertility. Common mental health conditions are things like depression, anxiety, OCD, and less commonly postpartum psychosis. In pregnancy, about 15 to 20 percent of women will experience mood disorders and very interestingly in the postpartum time frame, about 85 percent of women will experience mood disorders.

Host: So, along those lines, you know, I think what would be important to talk about are what are some of the signs and symptoms related to perinatal depression and anxiety? And, I think oftentimes this is picked up by their partner, their spouse, their loved ones. And so how can we tell our listeners about what to look for in individuals who are at risk for perinatal depression and anxiety?

Rachel Fargason, MD: I'll take that one, Dr. Huh. To meet the DSM 5 criterion for major depression, you would have one of two things. You'd either have a depressed mood most days with a sad, empty, or hopeless feeling. But what a lot of people don't realize, is that some people with depression don't have a depressed mood. What they have is a feeling of emptiness, diminished interest, loss of motivation, loss of pleasure, and find it very hard to get things done. And they may not have that much of an active feeling of depression. And then that might be combined with ongoing difficulty with sleep or sleeping too much, appetite changes, being anxious or feeling very slowed down, low energy, concentration difficulties, preoccupation with death, and sometimes, hopefully not too frequently, some suicidal ideation or intent.

You asked an interesting question, which is what would an observer or what would a loved one see in somebody who might be depressed? What they're going to see is the person might seem flattened out. They might not be as expressive as they usually are. They may not laugh at jokes. They may be humorless. Their face kind of stays flat. They don't, don't seem to enjoy anything. They might socially isolate, not be getting out with their friends or returning their friends calls. They might let their usual activities go, even though they want to do them, they don't seem to be able to get anything done. This is the motivation issue. So they'll let their house go. They may not keep up their responsibilities. They might talk more negatively too, and more constantly, you know, putting themselves down a lot.

As far as anxiety symptoms, anxiety is a whole class of disorders, as mentioned by Ms. Orr here. The most common form of anxiety is generalized anxiety disorder, and it's experienced in the patient as an excessive feeling of anxiety and worry all the time, or just this feeling of apprehension, like something really bad is going to happen. We all get anxious sometimes, sure.

But the difference is this person is anxious all the time. Their mind is just moving all the time, from one worry to the next. And they really can't control it. So it can interfere with their ability to work or concentrate or play with their other children. They might be restless, easily fatigued, can't concentrate. Their muscles are all tense. And the anxiety can interfere with sleep too, because the person can't relax and go to sleep. And then some of the other kinds of panic attacks Ms. Orr mentioned, obsessive compulsive disorder, which can commonly come out during pregnancy, and that's experienced in a lot of different ways, but a unifying feature is the repetitive intrusive thoughts that don't really make sense, but again, like other psychiatric conditions, they're hard to ignore and suppress, and sometimes the person will develop compulsive habits to try to counteract them.

Social anxiety disorder can worsen during pregnancy or postpartum. Excessive concern of embarrassing oneself in a social setting, and it can be impairing. The person may not be able to give presentations at work or use a public restroom. And then finally, panic attacks, which are very uncomfortable, abrupt surge of fear and physical symptoms, usually accompanied by like palpitations, dizziness, feeling they are choking or can't swallow, shortness of breath. And they're very unpleasant, and those can occur a couple of times a week.

Katy Orr, CRNP: Can I add, this may be helpful for the public to hear too, because a lot of times you don't really know what to say when you're going in to talk to somebody about this. And so it may be helpful to hear, in a clinic setting, what I hear a lot in both pregnancy and the postpartum, are things like I'm just here, or, I just feel overwhelmed, I don't know what to do, I'm scared, and that's a very common thing to hear over and over again in this population.

So I think people feel like it's a taboo thing to bring up or to, it's a vulnerable thing to put out there, but it's just, just for the public to know, it's very common to hear those things and it's okay to reach out and ask, hey, is this normal? Because I can't tell you how many times I've heard patients say I've never heard about this. No one told me to look out for this. Specifically when it comes to anxiety and the symptoms of panic disorder and obsessive compulsive disorder; it's not on their radar to be looking out for it.

Rachel Fargason, MD: It's very interesting what you said about the depression piece where they just really feel shut down because if you look at brain scans of people with depression, they don't look like the brain scans of people that are sad.

If somebody's sad, it's a very active, busy brain scan. If somebody's depressed, it's almost all black. It's an empty feeling. It's a lack of feeling. So it's a very different experience.

Host: Let me ask this question because I think, in the general public, we use the vernacular baby blues and could you just talk a little bit about what that is exactly and, I think that for our listeners and our audience, they probably would like to know definitionally when we mean by, what we mean by baby blues, but also talk a little bit about the significance of postpartum depression and anxiety as well.

For me, and this may be wrong, this kind of falls under the broader umbrella of perinatal mental health, but I think, we hear that baby blues term a lot and you mentioned it earlier, during this podcast. If you could just kind of clarify that further, that would be great.

Katy Orr, CRNP: Yeah. So the term baby blues, most people have heard or know about. I'll also hear just quote unquote postpartum and that seems to be like people kind of understand what you're talking about with a patient when you say, do you have postpartum? Also, it's interesting that that's kind of what it's turned into. Baby blues and postpartum depression and anxiety are very different things.

But one can lead into another. Baby blues usually starts a few hours to a few days after delivery. It is when a mother may feel a lot of mood changes, just up and down for no reason. They may have a lot of tearfulness that's really unexplained. Overall, they're able to function and provide for the baby and for themselves and it usually resolves within about two to three weeks.

 On the flip side of that, postpartum depression or anxiety, because we're seeing a lot of both at about the same rate, you can have baby blues that develops into postpartum depression or anxiety, or you may be totally fine until about three to six months postpartum, maybe even further out, and then develop these what we would call regular depression or anxiety symptoms that Dr. Fargason was listing earlier. It's more concerning, it is something that is going to be definitely longer lasting, possibly chronic, and that one, postpartum depression, is going to deserve evaluation and treatment.

Rachel Fargason, MD: Right. There's a big difference between somebody who's having a few episodes of weepiness or just some bad moments and somebody who's just flattened out or who just can't stop worrying. And that's the difference, really the difference between postpartum blues and, or anxiety versus a true psychiatric condition.

Katy Orr, CRNP: Something else I meant to say was it affects the way that the mother runs her day, runs her life. She may be letting other family members take care of the baby more. She may be in the bed more and just really doesn't, like you said, the social anxiety is a big factor as well. So it really affects the quality of her life. And, something that we talk about with our patients is where are you on the scale of how does your day go? How are you able to walk through your day?

Is it very difficult or is it just, I have a tear here or there and then I get over and I'm able to go on with my day. It's a good way to distinguish between the two.

Rachel Fargason, MD: Yeah. It's about functioning. I agree.

Host: As a parent and remembering my two girls when they were born, I just remember not getting much sleep. My question to both of you is how much does sleep deprivation play into some of this, both the baby blues and postpartum depression? I'm just asking because I remember those days being extremely hard and my wife being emotional and tearful about certain things, but I look back and was that because she was sleep deprived or something more to that or is this additive to this issue of depression?

Katy Orr, CRNP: As you can imagine, it has so much to do with development of some of these disorders. I wish I had statistic or a perfect percentage for this, but it seems that nearly every one of my patients that I talk to and ask, how is your sleep? I mean, understandably, they're going to be having choppy sleep through the night with a newborn. After about six weeks, the baby starts sleeping through the night typically. So at that point, things should get better.

But with anxiety and depression, I have women who will just lay awake at night, they're, they're thinking about is the baby breathing, they're thinking, did I lock the door or I need to go wash those baseboards. If you know, we're talking about like anxiety and the OCD tendencies. And some women who just won't go to sleep at all. They, they're just too hyped up. They can't settle. They're restless. It has such an effect on the rest of their day to day activities and it just really snowballs, the mood disorder, I think. So that's one of the first things that I talk with my patients about.

We'll get into treatments, but, that's one of my favorite treatments to talk about is how can we get you better sleep? What can we do? Can we bring someone else in to give you assurance that the baby's going to be looked over and kept safe so that you can relax and sleep. Is there medication that we need to talk about, whether it be supplements or prescription, that can help you sleep better.

Rachel Fargason, MD: Absolutely. I agree completely. So, sleep deprivation can make people, as we all know, very cranky, irritable, short tempered, lower our frustration tolerance, make us anxious, make us down because we have no energy to do things. But again, a big difference between just being sleep deprived and being clinically depressed or having an anxiety disorder is, what you were just alluding to, which is that you should be able to fall asleep when you have a chance to sleep.

And so if you're still lying awake, because many psychiatric conditions are heralded by, insomnia. And so if you're not sleeping because you're worrying constantly, then we're going to start worrying about an anxiety disorder. Or if you're not sleeping because you're having negative ruminations about what a bad mother you are or how you're not going to be able to mother.

 Although every person has some worries about that, but if it's constant again, it's all about, can you control it? Then, we're starting to bea little more worried about a psychiatric condition.

Host: Could you guys comment on, are there specific groups, demographics, risk factors that lead or increase the likelihood of perinatal mental health issues? I know you mentioned, Katy, that, 85 percent of the population has it, so that's pretty high, but it'd be important for us to know, what are those risk factors and are there particular groups that are at particular risk?

Rachel Fargason, MD: Yes, the most likely predisposing factor for developing a psychiatric diagnosis during the peripartum period would be having

a previous history of that diagnosis. So, while the hormones are surging, it's, it's even more likely, or dropping, it's even more likely to occur. So, having a current diagnosis at the time of, of conception, obviously, even having a previous diagnosis. There, there are some other things that do predispose people to developing psychiatric disease.

One is people who already have experienced hormonally related episodes of anxiety or OCD or depression. So for example, somebody who kind of fell apart at menarche, which is when a woman first begins her menses, a person who experiences a lot of psychiatric symptoms, maybe anxiety or depression or moodiness during her premenstrual period, say for that week or two before period.

 Those kind of people might be in particularly sensitive to hormonal changes. And some women who've undergone fertility treatments also will experience some discomfort when they're having certain kinds of hormonal treatments. Two other things that can predispose is having a family history of psychiatric disease does increase the risk and obviously a traumatic event around the, particularly around the time of the pregnancy.

Katy Orr, CRNP: And I would add one more thing maybe, just when, when reading through that question. I was thinking about how many patients that I see who are struggling relationally. So support system is so big. It's right after I ask the question about sleep. We talk about support system and who's there? Who do you have helping you and are you and the baby's father together? There are a lot of factors in relationships that can understandably affect a person's mood. And I just thought of one more thing, and I think that you said this, but just to kind of second it. I love it when someone comes to me and is in pregnancy asking for help because she has a history of postpartum depression.

She's scared that she's going to have it again. It just, is such a good thing that one can do for themself because it automatically decreases their chance of having it again if we're talking about it already.

Rachel Fargason, MD: You make such a good point because being pregnant, it brings about such a big change in your lifetime, any woman's lifetime, no matter how much support and well adapted she is. I mean, think about it, if you're having a baby, it's going to affect your family. It's going to affect your career. It's going to affect your relationships, it's going to affect your biology, and this is not a time to be alone and it's much harder if you're alone and unsupported. That does create a vulnerability for someone not to be in a supportive relationships.

Warner Huh, MD (Host): Well, this is fantastic. I couldn't ask for more for sort of laying the foundation of this topic. And you guys have talked about definitionally what we mean by perinatal mental health and the incidence and signs and symptoms and a little bit or more about sleep deprivation and the importance of support groups. This is actually perfect for our subsequent conversation that we'll have, in case the audience is curious, about how we manage this and treat this, and further we'll talk about resources and further awareness.

And those are topics I think that are delicate, but I think important for our listeners to understand. So I have to tell you, I'm like super excited about the second part of this. And, hope our audience finds the, the podcast really interesting. I did. But, stay tuned. For our audience, there's going to be a part two for this perinatal mental health discussion.

But again, I want to thank Dr. Fargason and Ms. Orr for coming. You guys did an amazing job. Thank you for setting the landscape. This podcast, frankly, was long overdue, so I'm happy that you guys are here. More to come. And as always to our listeners, please rate this podcast and we welcome any comments, particularly on topics that you're interested in.

And for more information on our women's services and our psychiatry services, please check out uabmedicine.org. Until next time, have a great day. Stay warm, happy 2025 and peace out. We'll see you again. Bye bye.