Psychiatry & Psychotherapy Podcast - Postpartum Depression with Dr. Pereau

Episode Date: April 24, 2018

Overcoming Postpartum Depression   Link to show on: iTunes, Google Play, Stitcher, Overcast, PlayerFM, PodBean, TuneIn, Podtail, Blubrry, Podfanatic This week on the podcast, I joined with Dr. Pereau to talk about postpartum depression, both from a personal level and as those who treat it in our patients. Dr. Pereau is incredibly honest and vulnerable in this emotional episode as she shares her story. Throughout it, she talks about the symptoms of her postpartum depression, including: Intrusive thoughts Emotional disconnection from her baby Sleep deprivation Hopelessness Problems with concentration Disconnection from passion and joy Panic attacks and anxiety Poor self care It had never occurred to Dr. Pereau that she would struggle with postpartum depression, though she had treated many people with it, and could easily recognize symptoms in others. Often, when we are experiencing these kinds of things, it's hard to identify the symptoms within ourselves. We understand the need for someone with a recognizable disorder, such as bipolar or schizophrenia, to get help. But depression can be a slippery, indefinable problem when it comes to labeling ourselves. If you are dealing with postpartum depression, know that it can be treated, and there absolutely hope to work through it. Here are some things that can help: Breastfeeding to stimulate connection and positive hormone production SSRI treatment (medications prescribed by a doctor) Talk therapy A good support system If you've been experiencing the symptoms we discuss in this podcast, there are plenty of resources, plenty of people who can help you during this time. The Edinburgh Postnatal Depression Scale is a simple questionnaire that can tell you if you are experiencing postpartum depression. For a list of local support groups in the region, www.postpartumprogress.com is a wonderful resource. Postpartum Support International is another great resource for online support groups and educational materials. www.postpartum.org   2020 Mom is an online advocacy group for maternal mental health. It includes blogs, educational materials and legal support. www.2020mom.org Below is a touching excerpt from her story: "My mother always said that when I had a child, I would know true love in a way I could never conceptualize. It had been a very long path to finally getting the child, and when he finally came I felt nothing. Actually, I felt worse than nothing. For the first couple months, all I can remember is darkness. I felt alone to my core. I felt like I was drifting, disconnected and lost. In my mind, my life was over. It was forfeit. The child wasn't a beaming ray of sunshine, filling me with hope and life and love. When I looked at him I felt nothing. The guilt of this overwhelmed me. I found myself wrestling through the options, fantasizing about packing a bag and running away in the middle of the night, or giving the baby up for adoption, or crashing my car off the edge of the mountain on my way home from work, or throwing myself off our cabin's third floor balcony. The images whirled through my mind and I would clench my teeth and force them away. It was all so dark. I didn't want him. I didn't want my life. I believed I knew these things for certain. I believed these were my thoughts. I mentioned to my husband Bryan about having a dream where I  jumped off the balcony, but then I quickly minimized it. I filled out the Edinburgh Scale in the OBGYN office with just enough depression items to be flagged but not enough to get hospitalized. We use the term, "A cry for help," and generally refer to something gamey or indicative of less severe illness. I can see how it looks that way. But I now know without any doubt what a cry for help really is. It was the weak, thready voice of the last piece of me left in my mind, the last flicker of light not darkened by postpartum depression. It was the last bit of me that was not pinned down under the weight of illness. Those weak cries were the best I was capable of. The illness was too great. My mind did not belong to me. My thoughts did not belong to me. I just didn't realize it. As a society, we believe that depression is something that can be willed away if a person is strong enough. If they just try hard enough. And yet nobody tells a schizophrenic to just try to not hallucinate. We don't tell a person with bipolar disorder to just try to not cash out their retirement to finish that half built bomb shelter in their back yard they've been building the last few weeks. Even conditions like alcoholism have been embraced within a medical model. We don't tell the alcoholic to just try to stop drinking anymore. We recognize this to be a medical illness deserving of care and treatment. And yet we tell the depressed person to try to be positive. Try to be happy. And I think I know why.  As humans on the planet, each of us suffer, faces grief, loss, and even hopelessness. And we find ways to survive, often becoming stronger because of it. We assume our experiences with emotional pain are similar to what a person with depression goes through. I know I thought that, and I've faced considerable loss throughout my life. Unfortunately, depression isn't anything like that. It's disease. It's organic. It's neuro chemical. It is an illness where your very thoughts become twisted and distorted, your perception of the world around you becomes altered. You lose who you are and generally have no idea that it's even happening. We have to stop assuming that depression is something like the subjective painful experiences we all encounter in life. It's a biological illness of the brain. In the past decade completed suicide rates in the United States have increased 20%, taking the lives of 121 people a day. Attempting to will away depression cost me 11 months of my life, where each month that passed took me deeper into a hole I couldn't claw out of. Postpartum depression affects the lives of over half a million women a year. It destroys families and severs the connection between a mother and child. It is a deadly disease which cannot be combatted through willpower. I believe a new approach is needed to proactively educate and better screen our patients. I don't begin to have all of the answers, but I can say that the culture around mental illness must change. There is no room for judgment. Maybe it starts with a simple, "I'm worried about you. I think you're hurting." Maybe it starts with spending the time to paint a clear biologic picture for the family surrounding a mother to heighten monitoring. All I know is that "holding it together" is no way to live, work, or raise a child. I chose to accept help. I chose to take medications to treat postpartum depression, nearly a year later. Eleven months after my son was born, I remember a pivotal moment. It was 3 in the morning and he had just fallen back to sleep, there in my arms. As I looked down at his beautiful face, there in the darkness, I whispered to him, "I would choose you." It was like it was the first time I had ever seen him. The Joy that normally present in my everyday life came back. My thoughts became my own again, no longer twisted and distorted. I have firsthand knowledge of what it looks like to be overcome by an illness of brain, of the mind. It's chemical. It's biological. And it's one of the most terrifying illnesses I can imagine.  And help exists. I know Sharing this helps to dispel shame, despite this being...a bit overwhelming. But it's seriously about life and death, and if hearing my story helps you to better understand what 1 in 7 women who have had a child is experiencing, then this is worth it to me." By listening to this episode, you can earn 0.75 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. Okay, welcome to the podcast. Today I am with a kind of one of the best of the best of the best of the best of the best. beacons of psychiatry in the community. She is someone I deeply respect and has mentored me indirectly, directly, and I've benefited from, gosh, a lot of the program she started. She is the director of the eating disorder program, the program for people with chronic PTSD, trauma. she's the director of the clerkship for the medical students. She's the assistant program director at Loma Linda here.

And she has her hands in so many things. She's, I would say, hyperthymic personality, meaning she has incredible energy just all the time. And she is deeply beloved by the students. She'll sit with the students for like an hour and talk career and help them plan their schedules, and she'll sit with the residents after tragedies. So truly an amazing psychiatrist, amazing person. I am honored that Dr. Perrault would come on to the show.

And today we are going to be talking about postpartum depression. And Dr. Perrault is willing to share her story. And it is not a usual thing for a psychiatrist to share their story. And I think one of the motivations here for Dr. Pro is maybe there's someone out there who would hear this, that it would reduce the stigma of getting treatment. And maybe she would be able to help one person. And with that, Dr. Pro, welcome to the podcast. Thank you. This is nerve-wracking in front of, like, other humans besides, like, the OB department.

Right. So, yeah, she gave this talk at the OB department here, but it's a little bit different, just putting it out there into the ether. Yeah. So tell me about your story as much as you'd be willing to share. My husband and I are both psychiatrists, which probably means our kid would be messed up no matter what. And I think that's a given. We've wanted a child for a long time. We did in vitro fertilization. We did a lot of work to conceive a child. And a little less than two years ago, we had a baby. And now coming in May, it'll be my son's second birthday. My mother had told me for all of my life that having a child would bring me joy

and that I would know a kind of love that I could not be able to understand or describe until I had actually had a child. and when my son was actually born, that didn't happen at all. I felt nothing. Actually, it was worse than nothing. For the first few months, it was really, really dark. I have little memory of a lot of that time, actually. I was alone to my core, and I felt like I was drifting, lost, disconnected.

In many ways, I felt like my life was over, that my life was forfeit. and that I didn't want a child and that it was the worst mistake I'd ever made in my life. Wow, that's just a heavy feeling coming out of, you know, such a strong desire to have a child, and then all of a sudden it's the exact opposite feeling and you're struggling with such dark thoughts. That must have been really, really hard.

Yeah, I think it was just so unexpected. You know, the pregnancy went very well, and some of the happiest I've ever been and getting the room ready and having all these really excited thoughts about this is going to be amazing. And then I'm there in that same room that I've painted and I'm sitting there with this baby in the dark thinking,

I don't want this. I don't feel anything. I don't know how to love this child and something is terribly wrong with me. I found myself oftentimes just sitting there and holding him and fantasy. about what would it be like if I just packed all my stuff and just took off and lived somewhere else. And it wasn't even like I'd be a psychiatrist somewhere else.

It was just like I would not be in this house with this baby somewhere else. And then some of the thoughts changed to, you know, what would happen if I gave him up for adoption. I mean, somebody would like this baby. I mean, he's a cute baby. They could take him. And then it was on my way home from work. There was a point where I thought, you know, I could. crash my car off the edge of the mountain. And it's a, you know, we drive up and down the mountain

every day and it's dangerous and, and no one would know, you know. And it got to the point where I would be on the balcony of the third floor of our cabin and think I could just throw myself over the edge of the balcony and all of this would end and it would not be something I was dealing with anymore. And I had never had thoughts like that in my life. And what strikes me is I remember you working and continuing to work. And that's, you know, I would have never known unless you would have shared this with me. Yeah, I think it didn't affect my work in ways that were visible to many people. And I think as physicians we compartmentalize so well that things like depression go so much.

farther than they might in the general population. They get to an end stage area of illness because they just build up and we just continue to compartmentalize them. Yeah. At what point did you realize that you were, you know, depressed? I realized there was a problem when I wouldn't take the baby out on the balcony. And it used to be my favorite part of the house because the view was amazing. And I told my husband, Brian, I said, had a weird dream last night about jumping off the balcony.

And I just kind of said it in passing, you know. And then I kind of minimized it. I went to see the OBGYN for my follow-up visits. I had a lot of complications postpartum and was actually hospitalized after the baby was born in the medical center for a few days. And I remember going to the clinic for the follow-up and doing the Edinburgh post-partum. partom scale and looking at the symptoms and realizing how many of them I had. But if I were to click all the boxes, I'd end up hospitalized. So I was just going to click a little bit less of the boxes so that it wouldn't be a, hey, let's lock this chick up, box clicking. Yeah. As a psychiatrist,

we know what that edge is. Which ones you click and which one you do. Yeah. Yeah, what did your, did you remember what your OB said to you at the time? They were more kind of focused on the the preeclampsia that had happened postpartum and, and, you know, it wasn't even something that really came up in the discussion. And I think it was more for me looking at, well, I clicked some of them rather than none. And I told him about this dream. That wasn't a dream at all. It was strong thoughts. And I realized that a part of me very much wanted help. And a part of me was in opposition to the rest of these very, very distorted thoughts. It was as if the part of me that was still healthy was a tiny, tiny little candle that was flickering in there. Yeah. So how long

did it go on like this? Eleven months. Eleven months. Yeah. And did you confide in anyone during that time that this was going on? Or did you just kind of? I truly didn't realize how much it was effect. me. And I had a saying during that whole period of time where I said, every day is the same day. I didn't, I was it, is it Wednesday? Is it February? I had no concept of time or the passage of time. I look at my phone and I have over 3,000 pictures of this child in the first 11 months. I mean, there's a lot of pictures and they're cute pictures. I don't remember taking most of them. Like, I don't remember the moments I look back and my memory is so foggy and so skewed from that period of time. And it wasn't like on a day-to-day basis I was forgetting

things. It's just the storage of information over 11 months was distorted. And so much of it was distorted by just thoughts that were product of illness. Did you have like pretty much all the classic symptoms of depression? Did you have the decreased interest, low energy? Yeah. You know, I think as far as postpartum depression goes, I think that a lot of the symptoms are just a little bit different than what you're going to see in regular major depressive disorder. I mean, you're not sleeping, but you say, well, it's because there's a baby there. You're, you know, having these intrusive thoughts about maybe you're going to get hurt or the baby's going to get hurt. But it's like, oh, but that's just because I've got this new baby and I've never had a baby. You know, you've got disconnection from the baby, but it's like, well, this is just really.

hard and I'm sleep deprived and tired, you know, and you don't have time to go out with people. You don't have time to have interest. You don't have time to get a shower or have hot food. You get to pick between a shower or hot food or neither. And so so much of the experience, I think I minimized and I didn't even realize how bad it was until it was at the point of jump off the balcony. And prior to that point, all of those symptoms were there, all of the issues as far as concentration motivation, there was no joy. There was not a single moment of joy during those 11 months that I can single out. Right.

So when the baby wasn't sleeping or when the baby was sleeping, were you able to sleep during that time? He didn't ever sleep more than 30 minutes at a time. Oh, yeah. I remember talking you about this. I was desperate. And even after, you know, I was very, very grateful for your help getting a sleep trainer and getting him on a schedule. Even with that, it still is, you know, it's difficult for him. And so a lot of this, I just attributed to poor sleep. And we had a nanny that we paid

to live in at night with us just so that we could get sleep at night and go to work the next day and not get, you know, bronchitis or whatever. So I was, I was sleeping when I didn't have him. but most of it was really more this feeling of hopelessness, this feeling of darkness, this lack of understanding of the passage of time, problems with concentration, problems with feeling joy, feeling passion, feeling connected to anything. I felt very disconnected and very lost. I think those are, yeah, that's a dark place. That's a dark place for sure.

So it seems like the light of like, oh, this is this is not normal. I should probably get help came on when you finally started to have these kind of suicidal thoughts of, you know, oh, I'd rather, kind of passive suicidal thoughts, suicidal thoughts with like kind of brief, intrusive thoughts on what you might do. Yeah, so who did you reach out to or what did you, you know, how did you go from, okay, I'm having these thoughts to. okay, I'm going to actually get some help. I think most of it was over time, as 11 months passed, we started, my husband and I started to realize this isn't just being tired and worn out from a new baby anymore. And the thoughts got better, as sleep got better and as I got more rest, the thoughts

diminished to some degree. but the overall feeling like I was dragging my feet every day, the overall feeling of being very disengaged was to the point where I think it was affecting my interactions with students and residents. I wasn't doing the things that I normally did to engage with them. I wasn't doing the things that normally brought me joy. And I think honestly, that was one of the biggest things

that made my husband and I say, let's go find me some kind of help. let's figure out what's going on here and is there treatment for this. Yeah, so it sounds like it was kind of the disconnection and the joy that comes from that connection that you normally have. I know that that's so important in your life and in my life and thinking through, you know, how you text probably a couple thousand times a day to the different residents and medical students.

To the point where I think they're really annoyed by it at this point. But no more meme, stop sending his pictures. I think they love it. Okay. So you started thinking through, I'm going to get some treatment. And as an attending, who pretty much knows everyone around here, it can be hard to get treatment, right? It can be hard to find a provider that's not like in our circle.

As psychiatrists, we get. referrals from other psychiatrists in the community. So it can be a little bit like, you know, who do you go and see? How do you get help? Yeah, any thoughts on that? Yeah, I mean, a lot of it is that we have a lot of good people in our community or, you know, further out that we interact with professionally or we interact with by name and we know them. And, you know, as a psychiatrist, yeah, it is hard to look for a psychiatrist within your own community because you're going to work with them or, you know, have supervised them in the past or whatever.

And I think a lot of that was just going, okay, let me go a little bit further than my own circle of people. And let me ask, you know, therapists that I know that I trust, you know, who is someone that you would recommend that we don't work with, who is providers that you've worked with. And so a lot of it was really looking at the networks and taking. them out as far as they went and going to confide in a few people that I knew that I thought could get me to the right people. That's good. That's good. Yeah, so have you worked with, I know you've worked with a number of patients with similar issues. Do any of their stories come to your mind in particular, stories that might be similar or a little bit different? Postpartum depression?

Yeah, I've treated quite a few patients with postpartum depression at this point. The OB department, you know, sends me referrals. And I love seeing them. One that was actually a pretty interesting one was when I was still pregnant. There was an administrative assistant that was sent directly to me to get help for postpartum depression. And it ended up being a woman who I'd never met and never worked with who wasn't anywhere near our circle. And yet I knew by title that this is a high-powered functioning person who has a desk and has other support staff and has got a good career.

And she came in to see me last minute because of an emergency referral. And she was wearing house slippers. and her hair was askew and she sat in the office within the first four minutes of meeting me and was sobbing. And I remember being pregnant and looking at her and thinking this is so terrible and so tragic and I want to help this woman. And nowhere in my mind was it, oh, I hope this doesn't happen to me. It didn't even occur to me. And it was something where I was able to work with her, you know, OB for lactation things and able to get her to the point. where she's functional and doing well and her kids doing great.

And it was a really interesting parallel to be pregnant to see this and yet not to recognize the similar parallels in my own life. I'm here six months later. Yeah. Yeah, I think in my own life, we had two kids, both of them with pretty significant colic. And I don't think I really understood, you know, when I was a medical student and,

And, you know, babies would come in with, you know, shaken baby syndrome or mothers that were very, very, very sleep deprived and depressed. You know, it's like I had no context understanding how someone could get to that place, you know, like a single mother who's got this child who just doesn't know, like, how to, how to sue them, how to calm them down. And then we had our kids and, you know, kind of like yours, like sleep. every half an hour they would wake up, would take them four to six hours to get them to sleep at night.

I had this big red ball, and for better or worse, I bounced Brooklyn and Luke for about from about 5 p.m. to about 12. And that's when I would finally put the child in the crib, and my wife would have had sleep a little bit during that time. I didn't work out on those days, did you? You know, I stopped working out. That that counts. I'm pretty sure that counts, bouncing a ball with a child.

There was no progress in my career at that time. I think even one of my programs kind of shut down and I just didn't care. I was just, you know, I didn't, I wasn't able to do so many things. I would just, you know, we were in survival mode. Yeah. And we were on that cusp, you know, of like, okay, we need to just do everything. everything we can just to get through this time and how many more months. And I won't speak for my wife, but we definitely tapped into some resources and got some help as well. But looking back now,

I'm like, okay, we had two people at home. We had some babysitters who would come. Like, how do people do this who just don't have any help? And that's one of the first things that I asked. the patients that come to me is like, okay, who's at home? What resources do you have? You know, how involved can you get your grandparents? You know, and even to the point of like bringing the husband in and saying, hey, like, you need to help here. Like, this is serious.

I've had a couple of patients who, you know, we send a partial day treatment program eight hours a day. And at first it's really hard to get them in because they need to, you know, get someone to get child care. Yeah. Yeah. Do you have similar sort of stories with patients and trying to get them to engage treatment or? I think a lot of it really does stem from this is an illness, just like depression in the non-postpartum setting where the person that is struggling with it is not necessarily aware that the symptoms are even happening. because if you think about biological illness, when we're talking about schizophrenia, bipolar, depression, the very nature of those illnesses is to lack insight.

It's an illness of the brain. And so you have a person that until it's affecting their ability to care for the child, until it's affecting their ability to care for the responsibilities at work or home, it can go unnoticed. and because everyone in the social structure in their support is also providing care and support. You know, you just assume that it's something that's just a normal part of child care. And I think so often the person with those symptoms just thinks I need to just work harder. I need to just will myself out of this. The number of times I purchased journals to try to journal out my way out of it to write things down about that, things I was grateful for with the baby, things that I should have joy about. And it's not that they spiraled into darkness or anything, but I mean, I made conscious efforts

to wail my way out of this thing. And I've seen so many patients do that and realize this is illness. This is a disease process. And so many of us still culturally, we think this is something that if you just try hard enough, it will go away. And even as a psychiatrist in the middle of an episode, that's my thought process. And at no point as a mental health professional or even as a person in society, do you tell a schizophrenic? Just try hard to not have voices.

You don't tell a person with bipolar disorder. Just try hard to not cash out the rest of your retirement to finish that underground bunker you've been building in your backyard for the past couple weeks. Even with an alcoholic, you don't, at this point, within the medical model, you don't really say to them, just try not to drink. We recognize those to be illnesses. And depression, whether it's postpartum, whether it's not within that context, depression is an illness just as severe, potentially more lethal, and something that as a society, we continue to say, just try harder. because I think for some reason, as a group of humans, we can look at our lives, we can look at the pain that's happened in our past. We've all suffered. We've all had loss. We've all dealt with grief. We've all had periods of hopelessness. And that links us and it binds us together. And yet at the same time, we assume that depression is similar to that.

And it is not. It is nothing even. close to that. And until you've had an episode, you've got treatment and you've come out of an episode and look back at it, you continue to conceptualize depression as something that you could subjectively understand. And it looks nothing like that. Yeah, there's a lot there. One thing that comes from my mind is you talk about that is kind of the variance of like severity of depression and what might work for different sort of severities of depression. So, you know, if you have mild depression, you know, maybe exercise, lifestyle, you know, therapy works, moderate depression, therapy is going to help, you know, at moderate levels,

most of my patients aren't, don't have the motivation to get any exercise or change lifestyle stuff. Medications works. When you get into the more severe depression, when you have, the suicidal thoughts when you have that sort of dark night of the soul, I think that's when, you know, therapy has some value, but it's got some limitations as well. Medications have a lot more value in that really dark, dark place. And, you know, I think when I, because I'm also thinking about the people who are very critical of, you know, medications and such like that. I think that a lot of people who practice at like, you know, in the big cities and they charge,

you know, $400, $500 an hour, they're not seeing the severe, severe depressions very often. And so, yeah, the lifestyle, exercise, you know, therapy may work for that type of person and may be sufficient. But when you're talking about more of the severe depression, you know, you really are talking about something very different. Yeah. And when you get into the suicidal thoughts, what's amazing is that a professional like yourself continues to work despite having those things. And we know that certain amount of certain percentage of physicians, maybe like around 10%, have those types of thoughts, but continue to work.

And we have all of the sort of, you know, psychological defenses against thinking that we need help. as well. Because we are, you know, as people, we are very resilient. And, um, and so I'm not surprised that you had like all of those defenses like, oh, this is something that's normal. I'm going to get through this. I'm just going to keep plowing the field here. Um, you know, I think that is something that also is built into people who are very resilient is to, to sort of keep moving despite, um, being in a dark place. And I think during the postpartum period, that biologic emphasis has to be a big part of it,

because postpartum depression, the majority of the time you're talking about something that has a very strong biologic basis that's not even secondary to a stressor. Certainly the stressor adds to that, but there are actually biologic changes within the brain that have happened secondary to the, pregnancy and to the delivery of a baby. And we're talking about over half a million women in

the United States have postpartum depression where we're getting to the point of severe depression and are meeting criteria for depression. And with suicide being the second leading cause of death in the postpartum period. And so it's a period of time where, yes, there is way more stress, but there is also a biological organic process that's occurring regardless of the stressor that's happening. Yeah, and I think evidence of that would be that all psychiatric illnesses have a higher rate of starting in that period. I've seen a lot of true manic patients in that period as well.

Yes, absolutely. You know, people that you hospitalized and you put on four to five medications, and after five nights, they're still up all night. Yes. Even on five medications, they're still pacing around, talking up a storm, you know. Yeah. So, and I know you've seen a bunch of those as well. Very, very difficult time period.

What do you think are some of the biological things going on? Like, you know, in that time period that puts women at higher risk? So there's definitely a massive drop in circulating hormones that, you know, during the pregnancy have been at high levels and come down. And so a big part of that, I mean, is the thought of the diminishing levels of estrogen progesterone, that because of the shift in the change in the hormones, something like postpartum blues is something that 80% of women with who have a baby go through, where you've got two to three weeks of some mood. crying, getting easily overwhelmed. That process that occurs is not solely because of, you know, you've added a baby and there's less sleep, but it's just those drastic decline in reproductive hormones. And so that's a normal biologic process that in a person with postpartum depression becomes much greater to that.

And those hormones actually have a role in the production of serotonin. And in addition to that, patients that have postpartum depression are found to have have diminished binding of serotonin to the 1A receptor in the brain. The majority of our medications that we're using to treat depression, we're hoping are going to be able to get more serotonin to the 1A receptor. There's a bunch of different serotonin receptors. 1A is really where you want to be aiming when you're treating depression, when you're treating anxiety.

So the very fact that that receptor and its ability to bind to serotonin diminishes by 20 percent in the postpartum depression brain is pretty substantial. And that's something that is found to be responsive to SSRI treatment. And also breastfeeding is something that can improve that binding potential as well. So you're talking about this happens in pretty much all women. The hormone decline happens in pretty much all women. The effects of those hormones on serotonin production occurs in all women, but in women who have postpartum depression, there's actually a change in the binding potential and the ability for serotonin to effectively work on 1A in specific parts of the brain, especially looking at the anterior cingulate, which is a part of the

brain that's very important for maternal bonding. And data that they've had for 60 years working with monkeys with this region looks at mothers no longer cradling their infants, no longer holding their infants attachment, maternal bonding, picking up on social cues. So you diminish the ability of serotonin to work within that region of the brain. And those are going to be the things directly affected. In addition to that, there's diminishing effect of serotonin on the 1A receptors in areas of hippocampus and areas of the amygdala, which affect formation of memory. Wow. Yeah. So you have all of that going on. And What are some things that can help that?

You know, certainly medication management to increase serotonin can help, especially if you have something that's targeting 1A specifically. Breastfeeding does have an effect on this and can improve the ability for binding on those receptors. And I think this is definitely something in people that have postpartum depression that is not seen in the normal population. So these are people that have a predisposition to this condition forming more likely. People that have a genetic predisposition, at least at times. And so medications can treat this, obviously, and breastfeeding an infant can also improve this issue.

So one of the things that comes up for pretty much every patient who I have this discussion with is, are these medications going to hurt? my baby. That is a phenomenally good question. And initially, when I first started treating patients with postpartum depression, I gave all of those patients searcherlien so loft because it has the least amount of transmission into the milk. And I just, it didn't matter if they did awesome on Prozac during the pregnancy for postpartum, or for depression during, I'd switch everybody's surreling. And what I ended up finding over the course of time was for some, it was helpful, it was effective. But for a number of them, the search really would help the depression to a certain degree, but they had had long histories of depression or anxiety in the past. They had medications that had

worked effectively really well for them. It had not necessarily been search relian, the Zoloft, and I have them on this medicine, and they get maybe 70% better, and they're doing more things, but they're still not really attaching to the child. They're still not feeling joy or passion, and not enjoying day-to-day life. They're existing, but at least they're getting dressed and getting out of bed and don't want to jump off a balcony. And so I talked with a number of the faculty in OB, and I'm like, so I'm just putting them all on search really much.

Is that like what I should be doing? And talking with a number of their faculty there, it's more the idea of there's incredible amounts of data for all of the medications that we use. And there are a handful that you absolutely don't breastfeed with. but there are a lot more medications that are safe that if you can treat depression down to remission, the likelihood the mother's going to attach with the child, the likelihood you're going to have good bonding, you're going to have healthier babies, healthier mothers, goes up if you use a medication that's been

effective in the past. And so I would definitely say for clinicians to be in close contact with the OBGYN, who has been involved with this person during the pregnancy to talk with them about safety data. There's a couple of great texts out about use of all medications, including psychotropic during lactation, that are phenomenal resources. And I would say that oftentimes we're overly cautious when actually you can look at serum levels in the infant. And there's studies both with infants and looking at animal models that are very safe. and the risk of not treating versus the risk of a small amount of that medication,

depending on the safety data, I think, needs to be considered. Yeah, and one of the things as someone who's analytically trained, you know, I've read a lot of Beatrice B.B.'s work on early infant attachment and the stillface experiment with Etronic. And a lot of those things have been looked at with postpartum depression. And so when I talk to mothers, I often will tell them, you know, there are risks of taking meds. And, you know, there are risks of not taking meds. Yeah.

The risks of not taking meds include, you know, more difficulties attaching to your baby. And I personally think that that is something that people don't have in their mind when they're thinking about this. And when they're thinking about the importance of it and sort of allocating resources to, kind of, you know, the family has to mobilize often to get the person to get into treatment effectively. And, you know, thinking about that early attachment, you know, Beatrice Bebiat was able to show that at four months, the way that a mother interacted with the infant predicted attachment at one year. And we know that attachment at one year predicts attachment at, you know, high school. Now, if you've been through postpartum depression

and you're listening to this and you're like, oh, no, I've moved my baby, well, they've also found that the attachment style of the mother, you know, in the early years, starting from age one to high school, you know, the attachment style of the mother actually was a greater predictor of the attachment style of the infant. So you can get secondarily kind of connect the infant can have that secure attachments. So you're not sort of doomed into a certain attachment style just from age one. so the best predictor of what attachment style the high schooler will have is the attachment style that the mother has and you can be secondarily if if you think that you might have insecure attachment or avoid an attachment style you can get good therapy and you can sort of move through

that as well so that all being said don't feel hopeless from that statement from myself but also know that that's a statement of you know this is something that's important it's It's important to get that treatment early on, and it's important to not waste time. This is not something that you do and then follow them up three months from now. You follow them up two weeks later, two weeks later, two weeks later, two weeks later, two weeks later, until they're no longer depressed. So, yeah, any other risks of untreated postpartum depression that you want to touch on? Yeah, I mean, certainly there are risks to the overall health of both the mother and the baby. If you have a person that's depressed and they're not taking care of their basic needs, obviously that can affect how they attach with the baby, but also how they function.

You know, I had postpartum preeclampsia, which I didn't even know was a thing. I didn't learn about at medical school. And I let it go for about 10 days. and I didn't go seek any kind of care until my blood pressure was like 2.30 over 146. And I got into the hospital and they just put the mag in my arm and I was just hospitalized at that point. And I think as far as for checkups for the child, I think that we definitely got him to the pediatrician. We did all the things that we needed to. But that urgency of how many months has it been, what vaccinations has he had, we were able to do those things.

but I think that that process would have been so much better had I been connected, had I been in tune. That could be guilt that comes with depression as well, right? I mean, I think as parents, we always have that great fear of like, am I doing everything possible for my infant? And it can be hard to struggle with that. It can be hard to struggle with that. And it certainly also looking at attachment also affects connection within the home. You know, connection with your spouse and identifying their own. emotional needs and how you fit in with that, being able to ask for help, being able to reach

out to your support network. The number of patients that I've treated with postpartum depression, and I say, you've got a mom who lives three miles away and your sister's out and Riverside, what are you doing, not calling these people? And they think, well, they didn't need help, so I shouldn't need help. And it's like, that is a distorted thought process. And those disorder of thought process isolate that person and keep them from getting help that is available to them oftentimes. Yeah, the shoulds of I should be able to do this on my own. I should be able to do this alone.

I shouldn't need help. All of those can be things that keep people from thriving and from overcoming. And there are things that are there for a reason. They're protective. They're adaptive, but they're also maladaptive. And so looking at them, looking at the all or nothing, thinking of them, and trying to help patients to realize that, yeah, this is a time where you need to pull on your resources. Yeah.

So any other things on risks of untreated postpartum depression that you want to touch on? Mainly just kind of finishing up as far as options for treatment for depression, I think before you even get there, you have to recognize that it's occurring. And if we already established that it's in the mind, of the person that's depressed, they may not see it. I think if there's only one thing that I can communicate during this discussion is that having symptoms of apathy, sadness, hopelessness, issues with motivation, energy, if those are occurring after three or four weeks of delivery, you're no longer in postpartum blues. You are no longer in a normal biologic state that 80% of

people will have a baby where they'll have tearfulness, they'll get overwhelmed. That is a normal part of you've just had a baby. But for a person to continue with those symptoms and have them go past a month, it's important for the patients to know this, but it's also important for their families to know. And so if they notice this person is getting still very overwhelmed or is disengaged, is hopeless, is helpless, is not connecting with the baby. And it's been two or three months, it's time to go seek help. And if that's the only one thing I can communicate, I would say that's incredibly important because so often we assume this is just because you have a baby when really it's illness. A couple things come to my mind as thinking about someone

in the community who might be listening to this and thinking about, okay, how do I get help? One is, you know, sometimes it takes three months to get into a psychiatrist. So what do you do if you're, you know, two, three weeks out and you're like, I'm starting to get very depressed. I don't know who I can get in to see. What would you say for that person to consider or think about doing or how would that person get help? Yeah. And in talking with the OBGYN department, that was kind of a big part of what we were doing because the idea of you do have checkups with your OB after the baby, but then by about six months,

you don't anymore. And for some people, this may not even show up until a month or two after delivery. And then those symptoms progress at that point. My thought process would be certainly if you can get into CER OBGYN, they are absolutely trained to manage this, to screen for this, and to help facilitate the beginning of treatment. There have been plenty of patients that come to see me and they're already a month on meds and I need to tinker with them and that's about it. The primary care physicians can also manage this. You know, I would feel very comfortable with a primary care physician, a nurse practitioner in a clinic managing this,

at least the initial symptoms, until a person can get in for further psychiatric care. Yeah, I think if the person is at a state where they're having the suicidal thoughts, you know, considering going to a psychiatric hospital for a couple days, is a good option. if a person has some passive suicidal thoughts and is on medication, another good treatment option in this day and age is like the intensive outpatient program or the partial program.

And a lot of academic centers have them, a lot of community centers have them now. They're the three-day-a-week to five-day-a-week programs, and that's kind of what I try to get in, the significantly severely depressed postpartum patients that I see. I agree that OBGYN primary care should be able to help manage this. And if you are having these symptoms, you can call your OBGYN that day. And if they don't get back to you, call them the next day.

And then if they don't get back to you, call them the next day. Sooner or later, you're going to get your voice heard that you need to be seen, that you need to get help. Because, you know, I know a lot of physicians are very busy, but we want to be able to help people who are in need. another thought is I will put up the depression scales, the two that are commonly used, so you can take it yourself or give them to your patients and see how they kind of score on the severity spectrum. Now, if you give it to patients, just to realize that some patients will not honestly fill them out.

And so after they fill them out, you can go over some of the more touchy questions. and kind of normalize it. Because in my experience, no mother ever wants to say that they want to hurt their baby, but often people's severe postpartum depression have fleeting thoughts about hurting their child. And to normalize it,

to say, you know, even if it's just a fleeting thought, it's helpful for me to know, if you're having fleeting thoughts, this is not something like, you know, I'm not going to lock you up, I'm not going to lock up, you know, take your baby away,

but I just need to know the severity of it so that I can know, what is the right treatment? Absolutely. If someone was in that sort of severe range of wanting to hurt their child, what would you advise what level of care would be the appropriate level of care? Got it. And we've seen patients like that, obviously in the inpatient level of care often.

I think some of it comes down to is this a fleeting thought in the back of their mind where they've had an image and it was distressing to them versus is something that they're dwelling on how severe is the depression that's presenting, how severe is the suicidality. I've treated patients in the past that had those as afflating thought and it showed up one time and they called the in-laws and said, I want you to help take care of the baby and be around more often and then brought the in-laws into the session. That patient did not need to go into a psychiatric hospital, but other ones who've had more complex thoughts, more ruminating thoughts, If it's to the point where there's thoughts about harming the baby,

then I would say a psychiatric hospitalization is an appropriate level of care. Excellent. Dr. Pro, thank you so much. Thank you so much. Is there anything else you wanted to mention? Yeah, I think probably the last thing that I wanted to kind of share is the idea that it took 11 months for me to come out of a depressive episode, and I'm able to look back and say, I have no idea how that happened. I had no idea how much time it took. And I remember a pivotal moment right before his first birthday.

It's like three in the morning, and I'm holding him. And he's just fallen asleep, and I looked down at him. And it's like I saw him for the very first time. And I thought to myself and whispered very quietly to him. I would choose you. And that was a very powerful moment for me, I think, because I was starting to come out of depression. I was able to see how distorted that period had been. And I got to experience joy starting to come back in my day to day of life.

My thoughts became my own again. the way that I interacted and interfaced with other people, improved, the way I connected them with my child improved, and I was able to look back and say, this was a very chemical, biological process that has occurred. And it was very, very important to take that step toward getting treatment. And I mean, this is a condition that you're talking about. One in seven women who have a child will meet the criteria for. And so making sure that families are aware of this, making sure that people who've had a baby are aware of this is important, and making sure that it's known that there are incredible treatment options where within a few weeks to a month, month and a half, your experience with your child, your experience on a day-to-day basis can change in powerful and amazing ways.

And I'm very, very grateful for that. And I have a newfound experience that allows me to have greater empathy for my patients. patience and have a better understanding of this thing that we're battling every day. Wow, that's, that's beautiful. That's really beautiful. It's, it's like that connection makes, it's, it's, it's that connection that your mother spoke about, right? Yes.

That you, you didn't understand initially, but now it's like, oh. Yes. This is, this is worth it. That's, those are the exact words. This is worth it. I would choose you. We'll leave it there. Thank you.