Psychiatry & Psychotherapy Podcast - Perinatal Mood and Anxiety Disorders

Episode Date: November 15, 2018

For many, motherhood is a beautiful, unique, and meaningful experience. The mother-child bond is a relationship that has the potential to be a deeply loving and positive experience for both the mother and child. However, motherhood can be distressing, which is why it is imperative that we, as providers, understand the unique psychiatric issues that are associated with this time period in a woman's life. Perinatal mood and anxiety disorders, or PMAD for short, is the term used to describe mood and anxiety disorders that affect women during the perinatal period, which is the timeframe from pregnancy to 12 months postpartum. PMAD encompasses a variety of disorders, such as anxiety, depression, obsessive-compulsive disorder, bipolar mood disorder, psychosis, and PTSD. Details on connecting with Kelly Rivinius through social media or about her free support group:here By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. Welcome back to the podcast. Today I am joined with Dr. Kelly Ravinius. is a licensed clinical therapist who is SID, a person that I refer clients to. She specializes

in care for women around the time of pregnancy and after, and all the issues that can develop postpartum depression. And so today I have brought her on and we're going to be talking about this period, the perinatal period. So Kelly, welcome to the podcast. Thank you. Yeah, so tell me a little bit about perinatal therapy. And what that entails, I know you run a group. Sure. I've referred some people to.

And so what are the types of issues that you treat in that period of time? Right. Well, the perinatal period typically is seen as from zero to 12 months postpartum. So we would say pregnancy through 12 months postpartum. So a woman who is experiencing, in this case, you know, paranatal depression, anxiety, obsessive-compulsive disorder, even bipolar mood disorder, psychosis, PTSD, all of those related to the perinatal period. So they often look very much like those disorders that would occur outside of pregnancy and the postpartum time. But there are some significant differences in their time. treatment that we can get into later.

Yeah, so what got you interested in this? Really, my own experience as a mother and having my first daughter four years ago and going through the process of at that point in pregnancy, I was a fellow in a psychoanalytic clinic and I was learning all of these things about attachment and the mother infant dyad. And I was really excited to put them into practice with my new baby coming up. But as I progressed in my pregnancy, I started noticing more and more anxiety happening. And it really got to the point where postpartum, I suffered with pretty intense, obsessional postpartum OCD and anxiety, postpartum anxiety.

And had a hard time recovering from that and really fought that throughout the first year of my daughter's life. And so doing some research on that. having some training now and just being a mom myself and having another daughter and such a different experience with that postpartum period. I'm really inspired and really motivated to try to make that perinatal period so much better for women through preventive care, through postpartum planning, through the right therapeutic methods. Wow. Thanks for sharing. Just for those who might not know what that looks like,

what does it look like to have kind of obsessional thoughts after the birth of your child? Like what types of thoughts were you having? What things were maybe unique to, yeah, that situation for yourself? Yeah. Yeah, well, it's interesting because, you know,

postpartum OCD really typically, or perinatal, we would say, because it can happen during pregnancy to typically send. centers around, you know, intrusive thoughts around the mother infant diet. So the baby thoughts about harming the baby, fears of harming the baby. So the mother typically sees herself as harmful to the baby in some way or potentially harmful. There's a lot of, if you have more compulsions, you do a lot of checking on the baby.

Is the baby breathing when asleep? is the baby just they may center around certain things like diaper rash they may center around mine was constipation is my baby filling enough diapers

and it can be very very intrusive to the point of like many experiences of OCD there are intrusive images intrusive thoughts and there's a lot of understandably fear

that surrounds that mother as she tries to bond with her baby and attach with that little one and yet also hold herself in check from harming the baby. She doesn't, with perinatal OCD, the mother doesn't have, we would say, an intention to harm the baby. It's very different from perinatal psychosis, which we can talk more about at some point. So there's no break from reality. The mother is very aware that these are very egotestonic thoughts and images. that she would never act on. Right.

So the mother has these thoughts, and they're incredibly distressing, the thoughts that I may harm my child. Right. But the thoughts are not to harm the child, which are actually more common than we would like to talk about, publicly probably, in postpartum depression, postpartum psychosis. I've treated a couple of patients with postpartum,

like OCD type of things around clobly. cleaning, getting up throughout the night, like, every 15 minutes to make sure the baby's alive and all sorts of things. And it's interesting that once you start talking to them, who are they sharing this with? You know? Right. Usually they, you know, only really the close family who are in that situation know about it. So yeah, that'll lead into maybe how we best help people who are going through this. So tell me a little bit about some of the other around post-pregnancy type of things that you see frequently that maybe sort of encompass this whole idea of perinatal psychology. Sure, sure. So we typically see, you know, there's postpartum depression is the one

that everyone thinks of. You know, it's almost like people refer to it in kind of lay terms as postpartum, just the term postpartum. You know, this woman's postpartum. Well, yes, a woman who's zero to 12 months after birth is postpartum, but it doesn't necessarily mean that that should be the label for the symptoms that she's experiencing. So she may have a depressed mood. A lot of times paranatal depression looks more like anger and even anxiety. Of course, you know those are often comorbid too. A lot of times the anger and anxiety can be directed toward the partner. So, you know, we know also from postpartum support international studying the partners' experience. Postpartum, we know that a partner can experience a parinatal mood disorder too.

And that's often affected by whether the mother is really entrenched in a parinatal mood disorder. disorder. So it's almost as if she shares that paramedal mood disorder potentially with the partner. So there's a lot of lashing out of the partner. And all of this, interestingly, and we can get into with some of this attachment stuff,

is some of this can be impacted by a person's adverse childhood experiences. And we see that in particular with fathers who experience a paranetal depression, that the higher level of adverse

childhood experiences, score the person may have, sometimes that correlates with the presence of postpartum depression. But of course, that's just when, you know, postpartum depression, postpartum OCD, anxiety. Yeah. And in a previous podcast, we talked about postpartum depression and had Dr. Pro come on. and that was really good to hear her story. What do you think in terms of is this genetic?

Is this the stressors going on? Is this how they were raised? What sort of things can kind of grow to the point that someone would struggle with either anxiety or OCD or psychosis or bipolar or PTSD? or depression in this sort of period. Sure. Well, I think we look at the treatment approach that's recommended,

and it's a three-pronged treatment. So it's medication and its therapy and its social support. And if you look at that, you'll understand even more about kind of what the origins are, perhaps, or we'll say maybe more the risk factors of a person developing, we call a P-MAD, which is a perinatal mood and anxiety disorder. So genetic, yeah. So what's the genetic history? What's the family history?

It's often really important for providers, first-line providers, especially, to get a really thorough genetic history from the mother at the first OB appointment. Of course, I would say also psychotherapists need to do a really, really thorough intake to get that genetic history so that we know if there's in particular a presence of, you know, bipolar mood disorder in the family or psychosis or even depression or anxiety or CD. And then there's personal history too. So we do see that there can be a correlation between whether a woman develops a parinatal mood and anxiety disorder and if she's already had, you know, prenatally or before

pregnancy, a history of, you know, personal depression, anxiety, etc. There's also an issue with the type of birth than a mother experiences when giving birth. So if she has a particularly transatlanticity, traumatic birth where the important thing here is not necessarily what we would say is objectively trauma. You know, we providers often look at, you know, what are the symptoms of PTSD? What are the criteria? But we're finding that a woman doesn't necessarily experience objectively the trauma. It's more important what she experiences subjectively. So if the birth didn't go according to plan, if she was scared a long time during the birth. If there's something where she felt very, very, very out of

control, a lot of us would say, well, you have a healthy baby, you're okay, you're fine. But a mother has a very difficult time sometimes processing those traumas, because that's how it feels to her, and then that can devolve into, you know, detachment from baby and fears and intrusive thoughts and depression, et cetera. Yeah. Yeah, with that one, I've seen a big, move towards the midwives because of the experience being at home and their comfort and their control and it's very planned. And I've seen a couple of our friends move that direction. Yeah. Because of their bad experiences in the hospital, I've heard, you know, it could go either way, right? People could have a bad experience there as well and then want to be in the hospital the next time

around. Right. But yeah, okay, anything else that comes to your mind with that? Yeah. So when a woman has a history, also, I would say, not just of mental health concern, but also, you know, hormonal imbalances. So we're looking at things like polycystic ovaries,

things like even diabetes, you know, even experience of gestational diabetes during pregnancy, a woman can be at increased risk for developing a parinatal mood and anxiety disorder. And we understand that that has to do with the very real

and important role that hormones play in the reproductive process and how hormones are really important in, you know, the first, I would say, year postpartum even in the way that the hormones shift and the changes that happen there. And incidentally, you know, a lot of people will say, well, is it baby blues or is it really a postpartum mental health concern? You know, baby blues happened about probably 80% of women. They are pretty transient. They last from a couple days after birth to two weeks, a postpartum. But, you know, there may be some crying, some weepiness, some tears.

And yet the mother recovers pretty quickly. And so that's definitely something to distinguish too. And those are just normal reactions to hormonal fluctuations that are happening postpartum. Wow, 80%. That's a lot higher. Very common to have baby blues. More like 20%, one in five women are now thought to have a parinatal wound and anxiety disorder. So to me, 80% experience baby blues.

That is a lot, but it does resolve after the first two weeks. And so we think, okay, especially with adequate sleep, that's an important one too. And partner support. The mom's pretty well on her way then to recovering. but compounded with inadequate sleep is one of the biggest besides personal history and genetic predisposition inadequate sleep is one of the biggest risk factors for developing a PMAD. Yeah. Yeah, no, I completely agree.

And I feel strongly when I see patients who are struggling with this to get the partner involved. Yeah. And sometimes, you know, I have to tell, you know, the partner, hey, you got to step up here. is like, this is a rare moment in your life where you're going to have to wake up throughout the night and do some of the roles, you know? Especially if the baby has colic, you know, and then it's like, you know, that's basically what we had times two. And so I was bouncing Luke or Brooklyn and my kids.

And sometimes from like seven o'clock at night to 12. Oh, man. Because it was just so hard for them to fall asleep. And then, you know, so giving my wife a big chunk of time and then making sure she goes to bed at, you know, seven when I take the kids, giving her that at least that chunk of time. And that was like, you know, how we in part fought to keep our sanity. Right. It's so important. And even that inadequate sleep can lead to, we know, more severe P-MADs, including the development of a manic episode and even the development. eventually of a postpartum psychosis. So sleep is so crucial and you're very right in that. And if you cannot get the partner involved, if there's, you know, I like to work with the partner

too and it's so crucial. And we can talk some more about the postpartum planning and how to get the partner involved even before the baby comes in that planning process. But then there are other people who can really be involved if the partner's not. For example, you know, postpartum doula, so, so important, you know. We love labor and delivery doulas as well. I think they do so much. and a postpartum doula can be so incredibly helpful. Really, her focus would be just on the mom to make sure mom is well. And mom has cared for while mom, too free mom up to focus on baby. Right.

Yeah. No, I, gosh, I think that that's so important. If anyone's listening to this and they're trying to figure out how to help their significant other, think about relieving some of the duties that surround normal day life so that the mother can focus on the infant. Right, right. You know, if you get a nanny, get the nanny to do everything, but hold the infant, you know? Have the mother be holding the infant or, you know, if mother needs a break, that's fine as well. Yeah.

But that gives me gone. So, yeah, any other sort of things that you wanted to mention there, risk factors for P-MADs? Sure, yeah. So also, you know, breastfeeding can be such an important. protective factor actually because of the hormones involved, the oxytocin and the way that breastfeeding can really actually give a mother a lift and we're finding be really protective against developing postpartum depression in particular. However, when breastfeeding does not go well, whether because of issues with latch, supply, whatever, that can be actually a very high risk factor

for developing something because it's so demoralizing for the mother often if she has wanted to breastfeed or has expected to do well breastfeeding. Absolutely. I mean, and that is something that I think is worthy of even finding expertise on. That was an issue for us, and we found out that both of our kids had lip ties and tongue ties. And one of our pediatricians said, oh, that's not a big deal. That'll go away in a couple months. And we're thinking, no, this child is not latching.

We're going to get this taken care of like as soon as possible. And after we did, it was. like night and day, 100% better latch, no pain during the latch. And so that's a real issue. You know, there's a flap of skin and you can feel it if you put your, if you have an infant and you put your finger on the top of their mouth and you move it across the top of their mouth. There's sometimes a flap of skin right in the middle. Yeah. And the same is true for the tongue on the bottom. And so they can have a tongue tie or a lip tie and they can have a lip tie on the bottom and the top or both. And so that makes it really, really hard to latch on. And so,

yeah, you could probably say more on that. Oh, definitely. And I've heard so many stories like that where once the latch was taken care of, breastfeeding went so much more smoothly. Mom is not in pain anymore. And because she's not in pain or she's not feeling, you know, like a failure, she can calm her baby now. She can feed her baby. She feels a lot closer to baby. She doesn't have. maybe the ambivalence or avoidance that she was starting to potentially experience because she felt so unsure about how to take care of baby. And, you know, some of the most wonderful resources, of course, for that are lactation consultants. And I always encourage mothers in their postpartum planning to make sure that they have the name of a couple of different lactation consultants

with whom they may meet before they even give birth. And they get snow and get comfortable with, get a feel for that consultant and their style and then really if possible either go as often as possible to the person's clinic or have them come to your home too. I experienced an incredible support team when I finally found them two weeks postpartum with my older daughter in the Riverside Women's Clinic from Riverside Community Hospital and those lactation consultants were like my lifesavers and even the second time around because every baby's different. You know, They helped me then too. Yeah.

Yeah, we had one as well. And it was, it was, I mean, we had a couple in the hospital who were trying to help us out and we were struggling. We were struggling. And then finally one was like, hey, this child has a lip tie. Yeah. And then we had another one when we got home. Yeah. And it was, it was wonderful.

She came to visit. She was very reasonable price. I mean, she was not trying to make a ton of money. She was just super passionate about what she was doing. Sure. And it made all the difference. Oh, it does. And, you know, if you aren't able to hire or feel like it's prohibitive somehow to have someone come to your home,

you know, I've mentioned this before, the breastfeeding clinic, or the breastfeeding support group at Loma Linda is wonderful too, because that's such a wonderful community of moms who've been there. Also lactation consultants who know what they're talking about, who can help with identifying lip ties as well and getting mom's support. Yeah. Yeah, and we'll try to put some resources in the blog that will go with this. And so you can follow it from the show notes. Okay. So any other sort of things that are unique around that time period that can cause

increased stress? Well, a couple of things, you know, there's antenatal trauma. So any trauma that's happened, maybe we talked about adverse childhood experiences, potentially that can impact the mother's experience of giving birth, especially of labor and delivery when the mother has felt very out of control, if they have had an experience in particular of sexual trauma in their past. And incidentally, the age of the mother. So I'm an older mother.

It's kind of a little bit a bitter pill to swallow that when you're an older mother, you tend to be at higher risk for developing a PMAD. And we're not exactly sure what pathway that is. Okay. I might add to that the engagement of the family support maybe and the husband. Yes. And I think that some men have this sort of weird idea that like everything is going to be taken care of by their spouse. And, you know, in this day and age, like you have to wake up.

to the reality that you are going to be helping and doing a lot and its life is going to change. And, you know, you're not going to be watching videos anymore. You're not going to be playing video games. You're going to have all hands on deck, especially if there's one of these issues going on. Right. And it's so crucial that the mother is started off in her journey of motherhood well. You know, I really believe that that is so crucial to her ability. to see herself as capable. You know, we talk about British pediatrician and psychoanalyst Winnicott

because he talks so much about the holding environment that the mother provides for the infant, ideally, and her ability to facilitate that good enough environment. And the mom doesn't have to be extraordinary. She just has to be able to be freed up to give herself all in to the care of the baby. And when she's not able to do that, whether because she feels unsupported or she has these other risk factors,

it's very, very hard. And so whatever anyone who's involved with that mother can do to facilitate that support, it's so important. You know, in a lot of Eastern cultures, the mother is just basically her only job, you know, at least for four weeks postpartum and then sometimes longer, is to hold and feed that baby, you know, nurse the baby, she keeps the baby in the bed with her. You know, I know we want to be safe and everything, but that's the culture. and she is pretty much in bed.

And, you know, some of us, you know, modern moms would be, or Western, I shouldn't say modern. Western moms would maybe chafe at the idea of staying in bed for four weeks, you know, but really the principle or the spirit of it stands in that the mother is cared for in the postpartum period, right? Yeah, yeah. And I'm really into like Beatrice Beebe's work, goals to have her on some day.

And we've been in email. contact. And she's really looked at, even at four months of life, you can make a prediction. Watching a videotape of the mother play with the infant. What type of attachment style this child is going to have at one year of life? Right, right. Is the child going to have an anxious attachment style, an avoidant attachment style, a disorganized attachment style?

And it comes back to what's going on in those first couple months of life. Yeah. And so, you know, it's so important, so important. And, you know, when I see mothers who get to my, by the time they get to my clinic, they usually want help. Right. And they want help as quickly as possible. Right. But if they're on the fence, you know, and we're talking risks and benefits and medications, you know, because they're our side effects and medications.

One of the things I always talk about is this, the risk. of being depressed and having that influence the child in a negative way. And this is something none of us would ever desire. Sure. But I know this is something you think about as well. Yeah, it really is. I am so passionate about treating the mother

because I know it's arguable perhaps, but I really believe that when we treat a mother, we are not only treating the mother, we're treating her children as well, because we're treating her ability to engage with those children and to attach with them and just to be that ordinary devoted mother when a cot talks about. And in my opinion, it's a preventive measure then. You know, you're treating the mother well, you're caring for the mother.

And so you're also preventing, you know, perhaps sequela of insecure attachment down the road or sequela of even trauma because we understand that, you know, attachment trauma can occur when a mother, sometimes when a mother hasn't had an ability to really bond with her baby and feels very low about her capacity as a mother and then begins to feel very distant from her baby. And it's much easier to, not that every mother does this at all, we never would say that, but it's much easier to be hurtful, unkind, even abusive toward someone that you don't feel, well around. Someone's a child that is, you see as difficult because they're crying with colic all the time or, you know, you just can't soothe them. And so we know that treating the mother

treats the child, which I see as a preventive measure, I see it even as a public health concern. Yeah. Yeah. And, you know, I see these, because I'm an adult psychiatrist. So most of the people that I see in adulthood, you know, a lot of my patients have had difficult sort of connections with their parents. And so the question, you know, is always in my mind, well, how would you prevent this on a large scale? And if that could be done, that would be amazing, you know? And how do you help someone sort of change that trajectory when most people aren't even really thinking about that. Sure, right.

And if you talk about it, you don't want to guilt people into feeling bad. And if you're listening to this and you want to improve things, you know, attachment styles if you change in a child. So let's say you have an insecure and avoidant and disorganized child. And then the attachment style of the parent changes. By the time they're 18, that child is most likely going to mirror what the parent's attachment is. Yeah. And so there's hope. Right. There's hope. Even if you, even if you had a pretty bad first couple years, I would say there's incredible hope. Work on yourself. Yeah. And you have to work on the way

that you connect and you attach. Right. How would you say is the best way to help someone with that? Well, I think, you know, if we're looking at a mother, you know, in the three-pronged approach to treatment, I would say, you know, her ability to maybe attend to the therapeutic process would be enhanced by medications, right? In many cases, especially if she's very severely depressed or anxious or having obsessional thoughts. Then also social support, but really, I believe that transference-based psychotherapy is the best way to heal attachment wounds. So define, um, transference focus for psychotherapy. It would be psychoanalytic, psychodynamic, theoretical orientations.

So the emphasis is on the relationship between the client and the therapist or the patient and the therapist and the dynamics that happen kind of in the room or in that relationship. So kind of all of the experiences of the person, the client, get laid on to the therapist. but the therapist is solid enough in that setting and strong enough and ethical enough to be able to handle that. We think of, it's like, you know, when I got talks about the baby's aggression toward the mother,

you know, when the mother can handle that aggression by being, continuing to be stable, continuing to be solid, and not being vindictive, at the, you know, baby biting the bad breast or whatever that doesn't give the milk when he wants it or whatever. When the mother's able to continue to maintain that holding environment, even in the face of the baby's aggression, the baby learns that his aggression is not overpowerful. He learns that he is not too much for the mother. And I really believe from my

experience with clients and my own experience as a client in transference-based work that that therapist, if the therapist is able to hold that container, we'll say, for the client and help the client understand that he or she is not too much for the therapist, that they can withstand the client's assaults, whatever those might be. then attachment wounds are healed. And I really believe that I've seen it happen. Yeah, and intuitively this makes sense, right? Because if the issue is between having relationships with other people,

then it makes sense that focusing on the relationship with a person, a therapist, and having a therapist be able to contain the emotions that you might feel totally. towards the therapist, even if they're really negative emotions, would be a very powerful experience. And I'm going to regress here a little bit, but I remember when we were going through training, we both attended a lecture series by Dr. Tar, who was a psychoanalyst. And I remember watching videos of Dr. Ravinius. and Dr. Tar was so enthusiastic about you. And I remember that specifically because I remember thinking like,

oh, I want to like a couple years ago. I wonder what happened to her. I wonder if I could hire her to see some of my patients. And because it was the mirroring that he picked up. And Dr. Tar is like, that's what he thinks about. He thinks about the connection, the moment to moment change in connectedness between two people in a room. and he picked up that you were like intuitive about that.

Like it was like just kind of something that came naturally to you, which after watching thousands of videos, it doesn't always come naturally. Well, I appreciate that. I mean, I remember that and I remember Dr. Tar's class was extremely helpful to me. And, you know, I think creating or developing even more of a passion for analytic work

and that relationship with the client, definitely. Yeah. So transference focus therapy. So it really puts an emphasis on the relationship that's in the room that's going on real time between you and your client. Sure. So can you give me any examples of how that sort of took place? Maybe try to change some of the variables. In a clinical setting from my experience?

Like how is that different than other types of therapy and maybe give an example of like what that looks, what that looked like. All right. Well, yeah. So we'll talk about, let's say there's an individual who comes in with, you know, relational trauma or we'll say attachment trauma. The person's maybe a 30-year-old mother of when a child tends to, tends toward anxious and ambivalent attachment, which would look more like, you know, really hard time making a decision. about if it's severe, pretty much anything. Maybe the person calls multiple times for, maybe gets a referral from their psychiatrist calls for therapy, but, you know, avoids returning the therapist's calls when the therapist

calls them back, schedules an appointment, and then calls back right before the appointment and says, oh, that's right, I can't, I can't make it, actually. So even before the person gets into the room with me, in my interactions with the person making the appointment, getting to know a little bit about them in a few minutes on the phone, I'm already hearing them. I guess it's communication, really. I'm hearing their style of communication. I'm hearing if they're avoidant. I'm hearing if they're anxious and ambivalent. And I'm hearing sometimes when they're disorganized, which we feel is very severe. more relational caregiver trauma. And so when the person finally gets in the room with me, you know, we talk about content. You know, they're free to bring anything into the room, but I don't really get stuck in the content with them

and maybe problem solving their specific, you know, days, activities as much as I do in helping them to understand more about their interpersonal and inter-psychic dynamics. So I'm listening for patterns in the, their communication with me. I'm listening for patterns and how they communicate with other people. What is the pattern of this person's communication? Is it a plea? Is it saying please pay attention to me, but they're saying it in a really unhelpful way and it's just not getting them what they want? Are they really ambivalent and they're having a hard time when people do draw close because they're

scared? And all that time, I'm trying to be also in touch with my own humanity and my own foibles to say not only making sure that the session is about the client, but that a couple of things, that I'm having more openness and welcoming in my spirit for that person because I understand that we're all human and we all have wounds. And I'm also paying attention to my countertransference, which is my reaction to them subjectively,

what am I bringing to the room, but also objective countertransference. What is the person pulling for from me? What do they want? What are they trying to tell me, but they just don't know how to say? It's like a little, you know, I have young children, so it's easy to keep up with an example of, you know, a toddler falling on the floor and a fit because she doesn't have the words yet to describe what's really going on inside.

And so I'm listening for that in all of the, maybe we would call acting out, it's just communication. That differs to me from, you know, cognitive behavioral work, even dialectical behavior work, which is very focused on obviously the behaviors of the person and how the thoughts line up with behaviors. I use those techniques in my practice. I think they're extremely helpful and they're evidence-based. And I believe in a lot of those studies. but I believe that for relational trauma, for attachment insecurity, we must go a step further

into being brave enough to bring ourselves in the room with the client. And there's good data, I don't know if you've seen it, comparing DBT to transference-focused therapy. And it was fairly equivalent with transference-focused therapy maybe making some of the more attachment shifts in the work. So, yeah, wow, that was a very good explanation, though, and I think that's helpful. So let's say you were meeting with someone who was concerned that they might have some issues. Sure.

Or let's just say, in general, to a person who's saying, hey, I don't want to be part of that 20%. Right, right. Yeah. What are some of the things that you do to help them plan? Yeah. I love seeing women when they're still pregnant because I, even at the very beginning of pregnancy, or honestly, if I'm really honest, I'll say I just love seeing, I see a lot of women and I love seeing women before they're even pregnant because they can plan for pregnancy and the postpartum period

with me and we get to do all of those, you know, the therapeutic work, of course, on, you know, their attachment and all of those wounds so that we can also help them. shift that attachment just a bit and be more aware of it when they do have their little one. But also we can influence how pregnancy goes because we understand also now from increasing research that when a mother experiences depression and or anxiety in pregnancy, it can affect the development of the fetus of the baby. And so, you know, and then she's not, if I'm able to plan with her and also be a part of the screening process during pregnancy, then I can know how high her risk level is and try to get that risk down. And so I love to see women in pregnancy. If I don't see

them in pregnancy, I want to see them as soon as I can postpartum. Honestly, a lot of mothers have a very hard time we're understanding with saying, yeah, I think there's something wrong. There's a huge stigma. I mean, we talk about the mental illness stigma. There is a huge stigma around parinatal mood and anxiety disorders. And I really believe that the more we screen for these like routinely at OB appointments and as psychotherapists, at psychiatric appointments, and the more that we talk about it and get, you know, survivor stories or we would say lived, people who have lived experience in their stories. And the more that we do to help the mother plan, I think the incident rate I'm hoping is going to drop. That's, that's what we hope for.

So we would hope, if you're a therapist or a psychiatrist or treating in mental health, that you would take this information and use it to help your patient's plan. And I think I'm going to, in the blog or we'll put up like a PDF of like some of the things that you can, do to plan. So how would you help them, for example, plan for sleep? Right, exactly. So it starts with helping the mother be aware of, you know, especially if she's a first time mother or if she's had a baby who actually slept really, really well the first time, helping her kind of get in touch with reality about infant sleep or newborn sleep, that they really do wake up quite frequently during the night. And no, it's not really common for them to sleep even in four hours.

stretches, you know, and that we're lucky if they sleep in two-hour stretches sometimes. And so really, honestly, a connection to reality is important there. And so then I would help the mother, I would list all the different categories with the mother of what is she going, what are her needs going to be postpartum? You know, a lot of women, especially women who are used to taking care of their own needs, even just unconsciously while they, you know, work on, you know, school or a career or something, they don't really think about what their needs are going to be postpartum and how a baby is going to affect that. And so I say, you know, let's be realistic here. You're going to need to sleep at some point. You can't stay up. That's, you know, really, you can't stay up. You're going to need

to eat. And so, and you're going to need to care for your personal hygiene. You're going to need to take a shower. You're going to need to wash your hair at some point. You're going to need to wear, you know, to dress. And so how are you going to make that happen? And so we map out all the different areas of needs, almost like a, you know, a little web diagram. And then I say, okay, let's look at each area of needs. So we have like sleep, nutrition, personal hygiene, potential need for medication, especially if she has some risk factors that may predispose her to developing a perinatal mood and anxiety disorder, breastfeeding support plan, a social support plan, who's she going to access just to commiserate about how hard it is to adjust?

And then I say, who are your people? Let's go through your life. Let's go through your supports. Who are your people? So we divide them into categories. Who are your personal people? Like, do you have a mother figure or a mother or a mother-in-law whom you feel comfortable with near you? do you have, and if you don't, can we, can you get to a doula, a postpartum dula, who's a wonderful mother figure in a pinch like that? Can, do you know whom you can call on to hold the baby while you sleep, you know, in between feedings? Who could you call on to feed you? Who can bring you food? Who can you call on to do some laundry for you? If your partner's not able to be, you know, some people have, my husband has a business. And so he was very supportive, took time off,

but had to keep his business running too. So sometimes you have to access other people to help you with household things, who are you going to call on for child care for older children if you already have children? And then, so we talk about her personal supports first. And we make a list. I hope for at least two people in each category. Sometimes that's not the case, but I hope for it. And then I say, okay, now before you have the baby, this is ideally during pregnancy,

I want you to call, this is very solution focused here. So, you know, obviously I use a lot of different techniques in this population. Yeah, that's good. Just to ask them, just to say, hey, is it okay if I call on you when the baby is born for help with getting me some sleep? Is it okay if I call on you for some meals? Is it okay if I call on you while I take a shower? Get the person's assent and then just pencil them in as your support. with their contact information, it's really important to me that's concrete for the mom because I know that she's, you know, she's not going to have time for that afterwards.

And then we look at who are your care providers. So who's your OB? Do you need to have your OB aware, you know, are you and your OB working together to know that you may need a prescription for some sort of SSRI following birth? and who are your psychiatrists in the area that you would feel comfortable also accessing for prescriptions? You know, obese will often prescribe, you know, initially, and then they like to refer to the psychiatrists for ongoing medication support. And then who also are your lactation consultants in the area like we talked about before,

whom can you call on for breastfeeding support? And then what I ideally like to have happen is for the mother to make at least one contact with each of those parties prior to giving birth. It sounds like a lot, but the nice thing is that it's over time, it's with the help of the therapist. I would say hopefully for the men listening, you know, help your wives do this or, you know, help your partner. Right.

You know, get in there and walk through these steps, you know, because this is important for you as well. And I would say for the men, you know, think through, okay, how are you going to take over certain roles? How are you going to, you know, step up during different parts of the sleep? How are you going to, you know, what are you going to cook when she's not able to cook? Right. You know, what takeout are you going to get? Exactly. You know, and how are you going to learn how to, you know, do some of the play with the child so that you can give, you know, I took our kids for a walk every morning. Yeah.

And gave Lindsay like a good, you know, 45 minutes to an hour. So important. Every morning that she could just kind of do what she needed to do. Yes. And, you know, I was out there with my baby. And that was, that was precious time. or at night taking the baby in the tub and just letting them swim around, get some exercise, get that, you know, get their, you know, for us, it's good to get that exercise. And then, you know, allow Lindsay to have a little bit of a break then as well.

So I think thinking through these things as a family unit with your partner and thinking through, you know, know, especially if the, if you've struggled with depression or any sort of psychiatric illness before, I would say that's when you probably should plan to have like a psychiatric visit, you know, sometime after birth. And you, you know, you can schedule that. And so if you're the partner, it's like, hey, I got to, you know, figure out how to get my wife there, sit with her, take the baby while she has the appointment. Yeah. You know, and make that a priority just to make sure we're headed in the right direction, you know, because a lot of people do want to get off medications during pregnancy.

And if my patients are motivated to do that, you know, that's something I definitely work with them on. That being said, you know, it's also a good conversation to have on what are the risks of medications? Are there risks for different things? And if there are, how big of a risk are they? for example with Zoloft I was reading I think it's only like 0.2% gets through so minimal the milk the milk to the infant so like the percentage that the mother takes is very very small in the infant um okay yeah anything else on that on that list I know I think we've been pretty exhaustive um yeah and I like that you added about the partner because that is really honestly a frontline person for the mother yeah and I think you know I wish we had family living by, but the other thing is, you know, if you have good relationships with your family, how long would be too long for them to stay and what would be a good time for them to come help out?

Right. You know, some people I know, it's more of a burden to have family stay for a couple weeks, and some people, it's like the respite that they need, right? Right. Right. So those are other things to think about. All right. So, Kelly, tell me, if you were. you know, an OB or primary care, how would you make the referral and when would you make the referral to a like a psychiatrist? Right. So ideally, um, you would be able to use some sort of screening instrument during pregnancy, which is the recommendation of postpartum sport international

that you start screening at the first OB appointment, one screen at least in the second trimester, one screen at least in the third trimester. And then a screen at the six week appointment, um, postpartum, although there is now some push for Obis to be seeing mothers sooner, especially mothers who have vulnerability to developing PMAIDS sooner than six weeks postpartum. So when you're, so ideally you would be looking at all this data, you know, this data that you're acquiring throughout the time that you're seeing the mother, and you would be checking to see if she's getting a positive score. on any of these screening instruments.

And there are a lot of them, but one of them, they use a lot as the Edinburgh Postnatal Depression screening. And if you get a positive, then you need to flag in your system that that mother has an increased risk. And then you need to start the conversation with the mother as an OB,

that they're, you know, whether you want to start trying to refer the mother during pregnancy to a specialist in, paranatal mood and anxiety disorders or help the mother, you know, work with the mother to get on board for a possible referral, you know, right after, probably, I would say, between two and four weeks postpartum. And then, so if you're getting a positive result from the Edinburgh scale or any of these other scales, then you're going to really want to pay attention and not let it go. and then you're going to refer the mom.

And this is one of the areas that's very difficult for providers because the referral process can often be really hard for the mother to latch on to and, you know, run with. Yeah. And I would say if you're an OB or a family medicine doc who's taken care of this population, then I would say get a relationship. with some therapists and some, you know, psychiatrists in your community, you know, a relationship where you can text them. And because often, you know, right now I'm not accepting new patients. But if someone does come through as like, hey, I have this emergency, can you see this person?

You know, I usually try to make time. Right. Right. And so having someone that you can refer them to, that you trust, you know, knowing who those people are. That's really, really important. That's really important. Definitely. I like what you said, that six weeks may be too long. That's what we're finding now. And that's what Postpartum Support International is kind of looking at,

that there may need to be recommendations that are sooner than that. Yeah. And I would also add to that referral piece that a warm handoff, as we know, is so much more helpful often. and more effective. So, for example, it's very helpful if you have a moment or your office has a moment to make the call with the client, I mean, with the patient. So if you're a family practitioner, if you're a pediatrician, then you're seeing the baby,

because of course it's important that pediatricians screen to, and they do for mothers, if you are an OB, that somehow someone from your office is sitting with them, mother or offering to sit with the mother to make that initial call that has been shown to be somewhat more effective in making sure that the referral actually gets followed through with. If that doesn't happen, then making the call yourself, like you've said, and texting. Obviously, when you have a relationship already built up with that provider, then it even means more. Yeah, and this is where it's so important to realize that most people have so much stigma about seeking help, whether it's a therapist or a psychiatrist, that it's going to be a person.

be really hard for them to actually push through that stigma. And so this is where, you know, knowing that I think is so important because the likelihood that they're going to just follow through if you give them a phone number is pretty low. Yeah, very low. And so this is where you may need to be like, hey, you know, this is my recommendation. And can you come back like in a week or two with your spouse. Right. And so we can just kind of check in on how the family's going and I can go over some things I recommend for the spouse to do and for you to do.

And then, you know, if the spouse is there to enlist them to be like, hey, this is really important. Yes. Yes. This is really important because it's like the ball is so easy to be dropped there. And then if you're like an OB and your next appointment, and it's like two months out. Right.

Or I don't know how many months out, but, you know, obese. Or they're long. Very busy. They're very busy. They're very busy. So I can understand it from their perspective as well, how difficult it is. But I've seen many wonderful OBs that build such good relationships with their patients. And the patients trust them that that makes a big difference in whether the patient is willing to take the obese referral for a psychiatrist.

or a psychotherapist simply because they trust the person, the OB. And that's something we found across the board. If you have a stronger therapeutic alliance with your patients, they will be more apt to take medications or follow recommendations. So yeah, I'm totally in alignment with that.

Well, Dr. Ravinius, any closing thoughts? I think this has been really, enjoyable for me and pretty thorough actually. One of the things that I was really struck by as I was thinking about this podcast was the phrase that I ran across from an abstract I read recently that said you know, postpartum depression is the thief that steals motherhood. And I think we all as practitioners and partners and support people need to band together to, you know, help the mother hold on to her motherhood. Obviously she's a mother, whether she has postpartum depression or not, but her experience of motherhood is different when she has

postpartum depression. Yeah. And so what we're going to do is we're going to have in the show notes link to Dr. Kelly Ravinius's Instagram and link to the podcast blog. And we'll try to create some good resources for you there. And if you have any questions, jump on one of our social medias. Ask Kelly, she has an amazing postpartum, peripartum Instagram account where she talks about all these issues. And so that can be of support. If you live in the area, L.A. area near Redlands, I know Dr. Ravinius has a free women's support group.

That meets once a week. actually this right now it's the second and fourth monday of each month and yeah it's in the evenings from six to seven 30 and there's a meal provided and babies are more than welcome to come to so we'll put some information on that and if it changes we will um update that is no longer going on if it's no longer going on hopefully it will go on um but anyways hope you enjoy this and have a great day