Dr. Daniel Knoepflmacher (Host): Welcome to On the Mind, the official podcast of the Weill Cornell Medicine Department of Psychiatry. I'm your host, Dr. Daniel Knoepflmacher. In each episode, I speak with experts in various aspects of psychiatry, psychotherapy, research, and other important topics on the mind. Our topic today is perinatal mental health.

The perinatal period, meaning the time leading up to, during, and after pregnancy, is marked by major hormonal, physiological, and psychological shifts. It's a milestone in life, often full of emotionally meaningful experiences that are romanticized in popular culture, but it also comes with an increased risk for depression, anxiety, and other psychiatric illnesses. Up to 20% of women may struggle with a mood or anxiety disorder during pregnancy. Pregnancy presents a unique challenge in psychiatry when patients who are pregnant are faced with decisions weighing the impact of medications versus the effects of untreated mental illness on a developing fetus. This falls within the expertise of reproductive psychiatrists who provide expert counsel to pregnant patients and other doctors navigating these important decisions during a critical period.

Today, I'm fortunate to have the perfect person to discuss perinatal mental health and answer the important questions that come up about psychiatric treatment around pregnancy. I'm pleased to welcome Dr. Alyson Gorun, who's the Associate Training Director of the New York-Presbyterian/Weill Cornell Medicine Psychiatry Residency Program. She's also the Director of Psychotherapy for the residency, and was recently appointed to be the acting director of the Aaron Stern MD-PhD Program in Psychodynamic Psychiatry. Alyson, thank you for joining me today.

Dr. Alyson Gorun: Thanks so much for having me.

Dr. Daniel Knoepflmacher: This is particularly fun, a special episode for me today because you're somebody that I speak to almost daily, because the two of us are dealing with the ins and outs of running a psychiatry residency. But I get a chance to talk to you about all of your deep expertise in this area.

And what I do always—you know, you're somebody who wears so many different hats. Just those titles alluded to this, but you're a reproductive psychiatrist, obviously. You're a trained psychoanalyst, and you're a real educator, educate people a lot about psychotherapy as well. With all of these hats that you wear, I'm wondering, how did this happen? How did you become the person who does all of these things?

Dr. Alyson Gorun: That's very generous. Thank you so much. I would say that it all started in sort of an interest that I've always had in the origins of how someone becomes who they are and what's their story. And I wanted to make some kind of impact on people's lives, and I thought, well, probably the place to make the biggest impact is if you start kind of at the beginning before everything happens where you can kind of shape it.

And I initially thought that meant that I'd be treating children actually. I thought that was the beginning of people's stories. But then I realized, wait a second, it's actually starting even before then. It starts during pregnancy—the story—and the years following. So, I wanted to learn more about how to help people really from the very beginning and change the trajectory for those just starting to become parents and also their babies.

Dr. Daniel Knoepflmacher: And that's the reproductive psychiatry part. You also are a psychoanalyst. What inspired you to really focus on psychotherapy as a psychiatrist?

Dr. Alyson Gorun: Yeah. I mean, in some ways, it's the same answer. Psychoanalysis helps you get to the root of things, to the very, very beginning of where things come from. And I see psychoanalysis and reproductive psychiatry being very much intertwined in terms of their interest in that. They sort of take different approaches to it in the biopsychosocial formulation, you would say. But at the end of the day, people in both those fields are very interested in the beginning.

Dr. Daniel Knoepflmacher: Well, I love your tie to story, because that's certainly something that drew me to psychiatry and to psychotherapy, that narrative and that's so central to human experience. I mentioned in the opening this idea of the perinatal period, what it encompasses, and that this is such a special stage in someone's life story. It comes with unique vulnerabilities.

There are psychiatric diagnoses that emerge sometimes for the first time during this period, yet there's also preexisting conditions that people already have had as diagnoses, but they could worsen during all of the changes that happen during pregnancy and postpartum. I wanted to see if we can talk about these two categories separately. Maybe this is an artificial distinction, I don't know. You'll tell me. But first, what are the most common psychiatric diagnoses that are associated with the perinatal period, and how prevalent are they?

Dr. Alyson Gorun: Yeah. So, I think the most common diagnoses are, peripartum depression, anxiety, obsessive compulsive disorder, and bipolar disorder. But in addition to sort of DSM-5 disorders, there's also a range of just psychological difficulties that can arise that, we wouldn't necessarily pathologize in any way. And there's a range of estimates for all of these conditions, with some being, I think, more or less studied. But I'll just say that perinatal depression impacts approximately 10% to 15% of pregnant women.

Dr. Daniel Knoepflmacher: A significant number. When you say perinatal depression, I just want to clarify for people listening, that would be depression during pregnancy, but also in the postpartum period?

Dr. Alyson Gorun: Yes. There's different kind of point prevalence estimates for different time periods. But if you kind of take it all together, it's about 10% to 15%.

Dr. Daniel Knoepflmacher: And you mentioned anxiety, OCD, and bipolar disorder. Some of these might be preexisting psychiatric diagnoses that somebody already knew they had going into pregnancy. I imagine there's others. You mentioned bipolar disorder. But also, common diagnoses like ADHD. We've done episodes here on eating disorder and schizophrenia, among others. How might people with these conditions be specifically impacted during pregnancy or the postpartum period?

Dr. Alyson Gorun: What I'd say is that there's a large literature for each of those conditions, which I won't have time to get into specifically. Just broadly, I would say preexisting psychiatric conditions are impacted by all the changes happening during pregnancy and postpartum. So, that's biological factors, psychological factors, psychosocial factors. And so, it could increase the risk of relapse, symptom worsening, and also new comorbidities. And there's a lot of different reasons for that. But one of the major reasons is all the hormonal changes that happen. So especially a sharp decline in estrogen and progesterone after birth, but also some really obvious ones, like the fact that you're sleep-deprived, and you have less time to exercise or engage in self-care.

Dr. Daniel Knoepflmacher: I can think right away of how those factors with mood disorders, thinking about sleep disruption, what that might mean for bipolar disorder and for depression. But there's so many factors there that you highlighted. When someone's coming to you as a reproductive psychiatrist, they're planning for a pregnancy and they know they have a history of a preexisting psychiatric diagnosis, how do you counsel them to help prevent a relapse when they're pregnant or postpartum?

Dr. Alyson Gorun: The first thing I do is I always start by asking them how they're feeling right now. Because ideally, you want to have a patient have their symptoms well-controlled before entering a pregnancy. And if you have that, then you can establish, okay, what's maintained your current stability? And that's going to be the key to help keep them stable during their pregnancy and postpartum when they're experiencing all of these stressors.

So usually, that conversation about what's helped them maintain stability may include a risk-benefit discussion about any medications they're taking, as well as non-pharmacological interventions, such as: are they in therapy, are they exercising, what kind of sleep are they getting, what's their nutrition status, and whatever stress regulation strategies they might use.

The other thing I always assess is what kind of childcare support someone is going to have in the postpartum, because that influences their ability to implement any of these non-pharmacological interventions I just mentioned. And I usually involve a support person in the family meeting to discuss how to monitor for symptoms of relapse. That way, we can address them quickly before they become more severe.

I also help the patient become more self-aware of what their own signals are that they're not doing well. So, things like maybe withdrawing from friends or feeling less interested in a hobby, et cetera, really, whatever that is, so that they can monitor themselves and make sure, again, we can kind of catch things very quickly if something happens, because we know it's going to be a stressful time period.

One additional conversation I have is I'll sometimes describe kind of common relevant shame-inducing thoughts and feelings that might arise in the peripartum, kind of specific to what their diagnosis is, so that I kind of give them kind of an open door to saying, "If these things happen, if you feel them, I really want to hear about them, and also they might be important to assessing how you're doing."

So, a really common example of that is a mother might question whether they should have had the baby, maybe they don't feel connected to their baby. So, that's really important for me to know because I need to assess whether that is part of a larger picture of depression.

Dr. Daniel Knoepflmacher: So, what are some of the ways you assess those factors to decide whether this is or isn't a part of a larger picture of depression?

Dr. Alyson Gorun: Usually, it's not an isolated symptom. Again, there can be kind of psychological conflicts that might be contributing to that that aren't part of a major depressive disorder. But if it is part of a major depressive disorder, you're going to have all those other symptoms that are typical of depression. So, issues with your sleep, feelings of guilt, feeling like you don't want to do anything, all the sort of classic stuff. But as I'll maybe talk about later, one of the difficulties with diagnosing depression and anxiety in the postpartum is that you've never done it before, so you don't really know what's normal or not normal and you may think, "Oh, I'm supposed to be up all night worrying about the baby and if the baby's breathing or not." And you may not recognize, "Oh wait, actually, that's a symptom of depression, and it's just a little bit too much." So, that's one of the things that I kind of help women parse out.

Dr. Daniel Knoepflmacher: I can just see how meaningful that must be for so many women who work with you because I can just imagine feeling so alone with those thoughts and having somebody who's an expert who can explain what is within the bounds of experiences and reassure them.

I'm eager to talk with you more about the psychological stuff, but we'll do that a little bit later. I want to turn to the most common conditions that, come up, which are depression and anxiety. How do these typically present during and after pregnancy?

Dr. Alyson Gorun: So like I mentioned, peripartum depression can present like a typical major depressive episode, but it also has these unique features that can make it more difficult to diagnose. So like I mentioned, when you're pregnant and when you're postpartum, disruptions in your sleep, disruptions in your appetite, and changes in your energy levels are common. You're going to be tired, you're going to be waking up all the time to feed the baby at night, and maybe you're eating more because the breastfeeding, or maybe you're really nauseous, so you're not eating as much. Some of those kind of classic symptoms that we use to diagnose depression may or may not be indicators of a major depressive disorder if they're abnormal. So, one validated scale that is out there that can be very useful is called the Edinburgh Postnatal Depression Scale, and that helps parse out the contributions of these neurovegetative symptoms to the possible depression.

Additionally, I just want to mention another phenomenon which is called postpartum blues. So, that's something that happens in the postpartum. It occurs in up to 80% of women. It's completely normal. But sometimes, it can be confused with depressive symptoms. The major difference is that it should self-resolve within two weeks. And although it has tearfulness, irritability, anxiety, and increased reactivity, it tends to kind of come and go rather than being really persistent.

Another unique feature of postpartum depression is that it can be very anxious actually, and there can be also agitation. And the anxious thoughts may be centered kind of around the baby and some of these new tasks that you're doing. So, worries about harm befalling the baby, fears of separations, or maybe even concerns about your ability to mother. So, the kind of anxiety wraps around those kinds of themes.

At times also, the depression, anxiety, especially in the postpartum can be accompanied by distress of intrusive thoughts, sometimes even about hurting the baby. But when those thoughts are egodystonic, which basically means they're distressing and the mother's like, "I would never act on those, and I'm really disturbed that I'm having them," there's no evidence that supports that the mother's actually going to act on them. So, they're really just intrusive thoughts, and sometimes just providing some psychoeducation of, "This is just anxiety. This doesn't mean anything about you or that something is actually going to happen," can help women a lot.

Dr. Daniel Knoepflmacher: What are the medications that are typically used to treat depression and anxiety during the peripartum period? And I guess I also want to know, what differences there are with these medications in how you prescribe them or manage them than you would at another period in somebody else's life that when they weren't pregnant?

Dr. Alyson Gorun: Great. So, the best medication to treat depression and anxiety during pregnancy is actually the one that effectively treated symptoms to remission before pregnancy. So, the reason for that is having depression and anxiety during a pregnancy is considered an exposure in and of itself that has independent impact on various pregnancy postpartum outcomes. So because of that, there is no single "best medication," because you're really weighing the risk of the exposure to the psychiatric illness versus the risk of exposure to a medication.

So that being said, there are some medications that are contraindicated during pregnancy. So at times, we do need to consider alternatives. And then, some medications have kind of more and higher quality data supporting their safety during pregnancy than others, so we do prefer medications that have more evidence to support its safety. But that being said, the decision about which medication to use or whether you need to switch medication or stop it is really an individualized conversation between a patient and her psychiatrist that's based on a lot of different factors, such as prior medication trials, what's the symptom severity, side effects from different medications, medical comorbidities during the pregnancy, and many other factors.

Dr. Daniel Knoepflmacher: What are a few of the medications that we know from large data sets that are lower risk?

Dr. Alyson Gorun: Again, it's always a risk discussion because even if, let's say, a medication has maybe not as much data for it, but that data is reassuring, but if that patient doesn't take that medication, something really bad happens, like they become suicidal or they need to be psychiatrically hospitalized, we may still prescribe something that has less data to it because it's actually the thing that treats the symptoms.

That being said, if you kind of have the ability to choose a medication for the first time for someone with depression and anxiety, really all of the SSRIs have a lot of safety data supporting their use. There may be a little bit more of a signal of something with Paxil. But otherwise, you really want to choose the medication that's actually going to treat their symptoms, and you want to take into consideration any side effects from those medications.

Recently, there's been a lot of good data for SNRIs. There have been good data for all different medications. So, I hesitate to actually answer the question, which is this is the medication, that's the medication, because I think it's really personalized.

Dr. Daniel Knoepflmacher: Very important. And I don't want to push you into recommending one medication. I understand it's a very individualized decision. At the same time, in the opposite direction, I am curious if you can share with those listening what are the medications that are contraindicated?

Dr. Alyson Gorun: Any medication that cause any kind of birth defects with sort of a high signal are things that we would generally try to avoid. The classic one is Depakote. So, that's something that, if you're prescribing that to a young woman, you want to counsel her on the risk of birth defects and make sure she's using contraception, and maybe you just don't even want to prescribe it to her, knowing that there's a risk of unplanned pregnancy.

But even with that, there are some medications that sometimes are the one that keeps them healthy, that the absolute risk is very low of some kind of congenital defect. But again, when you're weighing the risks for one side versus another, we may still use it.

Dr. Daniel Knoepflmacher: Thanks. Well, with pregnancy, there's always the consideration about impacts on the baby, and we just talked about the risk of congenital defects. This is a discussion that you just used the term risk-risk, weighing that as a risk-risk decision. So, the risks of the medication versus the risk of untreated maternal mental illness. Can you clue us in into how you have that discussion? Because it's different than discussions you might have at a different time in somebody's life.

Dr. Alyson Gorun: Definitely. And I always take a lot of time to discuss kind of the data with my patients about what do we know and what do we don't know about a certain medication during pregnancy. But it requires, again, a consideration of a large number of factors, including the nature of the patient's illness.

 Major depressive disorder can look really different in different people in terms of how bad it can get, how much it impairs their functioning. And considering what is the chance that this person will relapse if they're not taking this medication or if we switch the medication, and that can be based on things like genetics, what's their family history of a postpartum depression or peripartum depression, how many prior episodes have they had or have they looked at, et cetera.

And then, it's also important to consider what medications have already been trialed. So if someone has taken many different SSRIs, but whatever medication they're on right now is the one that actually worked, then why would we switch it to an SSRI? Clearly, they're going to have a relapse of symptoms if we do that.

We also always want to consider, again, non-pharmacological treatments been used. I don't want to leave out the importance of psychotherapy and how much that can treat symptoms. So, has this person had a trial, a real trial of psychotherapy to see if the symptoms respond to that?

So, there's lot of different factors to consider. But when I talk about the medications, I talk about the known and unknown risks of what we know from the data, what we don't know. And I look at kind of three major outcome areas on congenital, obstetric, and neurodevelopmental outcomes. And then, I also talk about what are the risks of exposure to the psychiatric illness itself.

Dr. Daniel Knoepflmacher: We've been talking about depression and some about anxiety during pregnancy and the postpartum period. There's unique risks with those. But specifically, another important element is psychosis during the perinatal period. I'm wondering what you look for and what steps you take to treat psychosis during this very vulnerable period.

Dr. Alyson Gorun: Great. And postpartum psychosis is a big topic. We also see it a lot in the news, unfortunately. So, just to kind of say a few basic things about what postpartum psychosis is.

So, postpartum psychosis is thought to be a variant of bipolar disorder, so not primary psychotic disorder. And when it occurs, it typically occurs in the first three to 10 days after delivery. And it's considered to be rare but very important to identify because it carries significant risks to both the mother and the baby. So, symptoms can actually wax and wane similar to delirium. So when I teach the residents about this, I always tell them, "You might be consulted to see a postpartum mother in the morning, and she seems totally normal. And then in the afternoon, you can get reports of her talking about delusions." And so, that's kind of sometimes how it can present. It can kind of wax and wane and kind of come and go. And it's really characterized by insomnia, mood fluctuations, irritability, disorganized behavior, potentially obsessive thoughts about the newborn, as well as cognitive symptoms, including things like disorientation and confusion.

And most importantly, there can be delusions that may be related to the baby and even hallucinations that potentially command in nature to hurt themselves or to hurt the baby. Because of that, the risk of suicide, it's about 5%, and the risk of infanticide is about 4%. So, this is really considered a psychiatric emergency, and the patient needs to be hospitalized immediately.

One thing I always tell people, though, is that although this can be kind of a scary illness, with the right medications, it's absolutely treatable.

Dr. Daniel Knoepflmacher: We've talked about a lot of the different treatments, and I'm wondering beyond the traditional SSRIs and other medications that we use in psychiatry for these conditions throughout the lifespan, there's been some developments in reproductive psychiatry with specific medication or medications for treating postpartum. Can you just say a few words about what are the newest developments in terms of psychiatric treatments for postpartum depression?

Dr. Alyson Gorun: Absolutely. And it's a very exciting time, because there's a lot of new medications coming out in the market. One that I just want to mention is called zuranolone. And I think it's a neuroactive steroid reproductive psychiatrists are really thinking about how to incorporate this into patient care, what are the best patients that respond to it logistically, how do we use it. But it's very, very promising and definitely very exciting.

Dr. Daniel Knoepflmacher: That's exciting to hear about these developments and knowing that reproductive psychiatry is an ongoing developing field, and there'll be hopefully more breakthroughs in the years to come.

I want to talk about the things that come up during the peripartum period as biological, psychological, and sociocultural phenomena. These factors are at play when it comes to these conditions. So, let's examine each aspect. I'll start with biology. And we don't expect you to go on for an hour and give us all this neurobiological stuff. I just want the basics. What's happening hormonally and neurobiologically during pregnancy and in that early postpartum period that makes people more psychiatrically vulnerable?

Dr. Alyson Gorun: Yeah. So, there's a lot going on, and this is an area of active and also very exciting research. So some of the things that are being studied, include genetic vulnerabilities, hormonal fluctuations in estrogen and progesterone, changes in interactive steroids and also GABAergic dysfunction, abnormal neurotransmitter levels or activity, hypothalamic pituitary adrenal axis dysregulation, neuroinflammatory shifts, oxytocin dysregulation and even potentially structural brain changes.

Dr. Daniel Knoepflmacher: What about the psychological factors? Can you describe how identity changes and role expectations, how this can contribute to perinatal distress?

Dr. Alyson Gorun: Absolutely. And as you can imagine and have experienced, having a baby is a major life transition that is both very exciting, but is a significant stressor. And these transitions can activate difficulties for people around things like separation, anger, dependency. I mean, the expectation that you have to keep a baby alive can be daunting, let alone trying to facilitate healthy development. And it can be more complicated when there's conflicting information from various experts about how to do this. So typically, expectations and roles change in every aspect of a patient's life, including managing work-life balance, dividing responsibilities with a partner, balancing needs with the baby's needs, among many others.

And then, all of your relationships are in flux. It's not just with your partner, but with your parents, with your siblings, with your friends. All of these things kind of change. Additionally, issues that maybe you had previously addressed in therapy or worked through may be re-experienced again, because the experience of becoming a parent can sometimes prompt a mother or father to revisit their own parents' experience, and then your experience as a child.

So, this can be a time of a lot of thinking, and maybe there can be new insights, maybe more of an ability to repair something, or potentially further recognition of maybe something that was missing.

Dr. Daniel Knoepflmacher: And what about the impact of popular cultural narratives about pregnancy and new parenthood, this joyful time of all these gauzy memories? There's a whole industry out there marketing products where they're romanticizing this milestone in life. Have you seen an impact of this when working with patients?

Dr. Alyson Gorun: Definitely. And I would say many mothers already struggle with kind of idealized fantasies about what motherhood is going to feel like, and also very high expectations of themselves as a mother. So, having that perpetuated in our cultural culture and society really doesn't help. Mothers often feel they're falling short of the expectations that they set for themselves or other people's expectations, and that can lead to intense self-criticism and a whole host of different negative feelings.

And, you know, I'll just say that having mixed feelings about being pregnant and becoming a mother, it's called maternal ambivalence, is actually completely normal. And normalizing that for mothers is really important.

Dr. Daniel Knoepflmacher: In addition to the life stressors that coincide with pregnancy, there's also significant evidence that's shown how negative social determinants of health and systemic biases disproportionately affect mothers from disadvantaged communities. Can you describe just briefly how these structural disparities impact people and how it may shape your work?

Dr. Alyson Gorun: Definitely. Well, across the country, Black women are twice as likely to experience postpartum depression, but half as likely to receive mental health treatment. And additionally, in New York City, Black, non-Hispanic women were 12 times more likely than White non-Hispanic women to die from pregnancy-related causes just between 2006 and 2010.

So, given these facts, and there's a lot more data and statistics that I could quote around this, I talk directly to my patients about these facts and about these disparities. And I counsel them on how to discuss their concerns with their obstetrician, how to seek out additional resources and support, such as finding a group that focuses on these kinds of issues, getting a doula, having some kind of advocate that can provide both emotional support but also practical strategies

Dr. Daniel Knoepflmacher: Important to think about people are planning pregnancy, I imagine. Thank you for explaining that. Can you describe the different psychotherapies that are most helpful for peripartum depression and anxiety?

Dr. Alyson Gorun: Psychotherapy is actually the recommended first-line treatment for mild depression during the postpartum period. For moderate to severe depression with suicidal thoughts or any kind of impaired functioning, medication should also be strongly considered alongside psychotherapy. Cognitive behavioral therapy and interpersonal psychotherapy have the largest evidence base for psychotherapies treating postpartum depression.

Studies have found that although there is a significant reduction in depressive symptoms with both cognitive behavioral therapy and interpersonal psychotherapy, there are some mothers who are left with persistent symptoms. There are also fewer studies of psychodynamic psychotherapy, but the studies that have looked at it have shown that it is likely effective.

Dr. Daniel Knoepflmacher: So, lots of treatments, which is fortunate, but that means there's choices. So, how do people consider one modality versus another?

Dr. Alyson Gorun: So, many factors go into choosing what modality a patient may want to engage with. I think, the first and foremost is what therapy is actually available and accessible to the patient. So, that includes cost of sessions, what's going to be in-network, and also the availability of trained providers in that modality.

Patient preference for a skills-based therapy or for something more focused on insight and meaning may also play a role because we know patient preference impacts engagement and retention in that modality. And then, there's certain diagnoses that there's more evidence base for one versus another.

So for something like obsessive-compulsive disorder, CBT, cognitive behavioral therapy, is really the most effective treatment. And then, if a patient is having a lot of externalizing behavior such as self-harm or eating disorder symptoms or substance use, recent suicide attempts, again, you kind of want to choose the evidence-based psychotherapy for that, that you would choose whether they were pregnant and not pregnant. And then, psychodynamic approaches might be more valuable for complex or chronic depressions that worsen the postpartum or for patients with histories of childhood trauma or comorbid personality disorders.

Dr. Daniel Knoepflmacher: What are the common themes that come up in psychotherapy that you encounter in your work and how do you address them in the psychotherapy?

Dr. Alyson Gorun: Yeah. So, I actually co-wrote a book with Fred Busch that's titled "Postpartum Problem-Focused Psychodynamic Psychotherapy." And in that book, we outline five major themes that tend to occur in the postpartum period. So, the first one is a patient having difficulty tolerating anger, especially towards their baby.

So in psychodynamic theory, ambivalence, like I mentioned before, is the idea that someone can hold two opposing feelings or thoughts, and that normal to have in any relationships. But for many parents, the idea that you could both love your baby, but also sometimes hate them can be kind of intolerable, and this might lead to a defensive denial or, if they're a little bit more aware of it, anxiety, shame, or guilt about the fact that sometimes they feel that way towards their baby.

Parents may also be afraid that feeling angry can hurt their baby or that the fact that they feel angry means that they're a bad mother, which again, can lead to guilt or maybe expectations of punishment that can look like depression and anxiety. This also can sometimes look like catastrophic anxiety about harm befalling the baby.

 The next theme is parents having idealized expectations of parenthood, which we already talked a little bit about how that gets reflected in society and culture. So, parents might feel like they have to be perfect parents and, when they don't meet that expectation, can experience self-criticism, anxiety, and even anger directed towards themselves.

So, having unrealistic high expectations of oneself, it may be more present for a parent that has maybe underlying feelings of inadequacy or worries about their ability to be a parent. And sometimes these idealized expectations can be projected onto the baby. There might be a worry that there's something wrong with their baby, or maybe even they've produced a defective child, and that can lead to even more feelings of deficiency as a parent.

Third are conflicts about being dependent and also depended on. That can really reemerge during the postpartum time period when it's almost impossible to not have to rely on others for support. So, increased dependency on others for some people may lead to fears of abandonment or a sense that a patient's needs are going to go unmet. So for some, being overly dependent can lead to a parent feeling that they're maybe incapable of meeting the baby's needs or leading to an over-reliance on others for decision-making organization.

Others struggles with their dependency needs and avoid delegating tasks to others or won't get more support despite the lack of support negatively impacting their mental health. So, this may be for a whole host of reasons, but perhaps they received suboptimal care as a child, which led them to feeling like they need to be self-sufficient. They may struggle to trust other peoples or anticipate others won't help. Or maybe they feel angry that their children are receiving something that they didn't.

The fourth theme are fears surrounding separation and abandonment. That's also an extremely common presentation. And at times, this may even interfere with patients coming to appointments. So in this theme, the experience of separation is felt to be dangerous and destructive. Oftentimes, a patient who maybe has experienced an abrupt or traumatic loss or abandonment in their life will be especially vulnerable to intense feelings around the separation process. And it's not just about the physical separation, but it also may be about emotional separation. So, there may be a feeling that the emotional bond to the baby is particularly fragile in some way.

The final theme is related to difficulties arising from fears of intrusion. So, some patients might feel that the baby's needs are going to overwhelm them and lead to a disruption in their own identity or independence. They might feel actually controlled by the baby. This can also lead to patients sometimes always wanting to be present, because they actually feel guilty that they're feeling the need to sort of get away from the baby.

So in my work, I use psychodynamic techniques to help patient understand the origins of these feelings and link them to unconscious determinants to help make them more conscious. But there are a lot more details in the book in terms of how to address all of those themes.

Dr. Daniel Knoepflmacher: I just want to say that for those who are working with people in the peripartum period, I highly recommend the book that Alyson mentioned, which is about postpartum problem-focused psychodynamic psychotherapy, because you will see these themes come up commonly, and there's great tools in terms of how to help people process this and understand these themes and work through it in psychotherapy.

I realize we've used up a lot of our time, and I want to maybe kind of condense things a bit and ask you just what are a few key points about perinatal health that you wish all patients and families knew?

Dr. Alyson Gorun: One of the most important skills a new mother can develop from the start is flexibility. So not everything is going to go as you may have wanted or planned during the pregnancy, during delivery, or in the immediate postpartum period. And the more open you are to various kind of good enough ways that these events can unfold, the less distress you're going to experience.

Many women also think that the postpartum period should be hard and can miss that they're actually experiencing a postpartum depressive or anxiety disorder. I'd hope that they and their partners, would kind of seek out professional help if they're not sure if what they're experiencing is too much or not.

And like I mentioned, they've never done this before, so they don't really know what's normal. But you should be able to fall asleep when you have the opportunity to fall asleep. You should be able to take breaks. You should be able to delegate tasks to others, and you should have some kind of bond to the baby. So, I would encourage anyone who is having a hard time to consult with someone if they're concerned that things might be more difficult than it should be.

Dr. Daniel Knoepflmacher: What about clinicians? I mean, if these people are going to seek help maybe from their clinicians, what are a few key points you'd want them to consider working with patients who are in the peripartum period?

Dr. Alyson Gorun: Well, I would want them to learn about the safety of psychiatric medications during pregnancy, and also remember that withholding a medication also carries the potential for harm. So, it's truly a risk-risk discussion when making decisions about medications during pregnancy.

I'd also like to remind them of the importance of psychosocial stressors during the peripartum. I've had patients get one night of good sleep, and their depressive and anxiety symptoms resolve. So, always keep that in mind. Additionally, I'd consider all women who have a period as potentially childbearing and would always keep in mind the reproductive safety of a woman's medications and inquire as to her fertility plans so that if you do want to make an adjustment, there's adequate time to do so.

Dr. Daniel Knoepflmacher: What are some resources online that you recommend to people who want to get more information on perinatal mental health?

Dr. Alyson Gorun: So, there are a lot of resources online. I'll just mention a few. The first is the National Reproductive Psychiatry Curriculum. That is an invaluable resource for learning more about reproductive psychiatry and offers a lot of different training materials for clinicians. Reprotox is a helpful website for finding summaries of available data on medications. So if you quickly want to look something up, you can kind of go there. Additionally, LactMed is a particularly good resource for checking the safety of medications while breastfeeding. And then, postpartum.net is a great resource that offers online support groups for peripartum patients, has a list of reproductive psychiatry specialists in every state, and also has a lot of information for patients and partners about mental health issues.

Dr. Daniel Knoepflmacher: Alyson, one last question, which is maybe slightly off topic, but I mentioned in the beginning when I was introducing you that you are now the acting Director of the Aaron Stern, MD, PhD program in psychodynamic psychiatry. It's a long title. Can you describe what this role is? Because know it's important and I want people to hear about it.

Dr. Alyson Gorun: Yes, happy to talk about that. So, the mission of the Aaron Stern, MD, PhD program in psychodynamic psychiatry is to increase access to and utilization of psychodynamic psychiatry concepts and approaches in education, clinical care, and research across all medical specialties, not just for psychiatrists. So, psychodynamic approaches, which I've included a lot of them in today's podcast, are vital to managing complex or challenging patient interactions, and they also improve patient outcomes and physician satisfaction.

However, it seems that psychodynamic concepts are actually really underutilized in clinical care, especially outside the field of psychiatry, and are often inadequately taught or absent in residency training, including in many psychiatry programs. So, it's really essential that physicians across all medical specialties learn to apply psychodynamic principles in their everyday patient interactions, and that's what the program is hoping to address.

Dr. Daniel Knoepflmacher: Well, as you said, I mean, we got to see the value of psychodynamic thinking in a lot of what you said today. I'm very excited to have you in that role and it's obviously going to be a benefit for our residency, but also for the field to have these principles really being disseminated, because I'm a true believer in their value.

Alyson, I get to talk to you virtually every day at work and am constantly coming to you for your wise counsel, your sensible approach to everything. So, I'm glad that everybody who is listening got to hear that in action today. So, thank you so much for joining me and talking about this really important topic today.

Dr. Alyson Gorun: Thanks, Daniel for, inviting me.

Dr. Daniel Knoepflmacher: Absolutely, my pleasure. And I also want to thank everybody out there who is listening to this episode of On the Mind. As you probably know, we're the official podcast of the Weill Cornell Medicine Department of Psychiatry. Our podcast is available on many major audio streaming platforms. You know what they are, Spotify, Apple Podcasts, YouTube, et cetera.

If you like what you heard today, I'm going to say this again. If you like what you heard today, please give us a rating and subscribe. That way, you'll stay up to date with all of our latest episodes. And if you've already done that, thank you. it's very appreciated. Please tell your friends. We keep growing in our listenership every month, and I want that to continue because I feel very committed to trying to get the message about mental health out there in the world and help people learn about these important topics. We're going to be back again, in just a few weeks with another episode. So until then, wishing you good health in body and mind

Back to Health promo: Back To Health is your source for the latest in health, wellness, and medical care for the whole family. Our team of world-renowned physicians at Weill Cornell Medicine are having in-depth conversations covering trending health topics, wellness tips, and medical breakthroughs. With the spotlight on our collaborative approach to patient care, this series will present cutting-edge treatments, innovative therapies, as well as real-life stories that will answer common questions for both patients and their caregivers. Subscribe wherever you listen to podcasts. Also, don't forget to rate us five stars.

disclaimer: All information contained in this podcast is intended for informational and educational purposes. The information is not intended nor suited to be a replacement or substitute for professional medical treatment or for professional medical advice relative to a specific medical question or condition. We urge you to always seek the advice of your physician or medical professional with respect to your medical condition or questions. Weill Cornell Medicine makes no warranty, guarantee, or representation as to the accuracy or sufficiency of the information featured in this podcast, and any reliance on such information is done at your own risk.

Participants may have consulting, equity, board membership, or other relationships with pharmaceutical, biotech, or device companies unrelated to their role in this podcast. No payments have been made by any company to endorse any treatments, devices, or procedures. And Weill Cornell Medicine does not endorse, approve, or recommend any product, service, or entity mentioned in this podcast.

Opinions expressed in this podcast are those of the speaker and do not represent the perspectives of Weill Cornell Medicine as an institution.