Two interesting news items related to postpartum depression popped up this past week. The first is news that researchers have identified a link between an oxytocin receptor blood marker in some women which increased their likelihood of experiencing postpartum depression. What does this mean? Well, if there were a blood test to give pregnant women to identify which ones were more likely to experience postpartum depression, we could proactively identify those women, doctors and families could put supports into place for the postpartum period ahead of time. 

The second story is about a change in recommendations from the US Preventive Services Task Force about screening adults for depression. Now, if you're like me, you might be asking yourself what the US Preventive Services Task Force (USPSTF) is and what they do. Turns out, The Task Force is convened by Congress and reviews current clinical research to "improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications." This Task Force is now recommending that all adults be screened for depression because of its prevalence (1 in 10 all adults in the US will experience depression), and they specifically identified that all pregnant and postpartum women be screened. 

It's great when postpartum depression gets media attention. It increases awareness of the huge number of families affected by emotional complications in pregnancy and postpartum . Screening and identifying those who are suffering is a critical first step. 

However, there's an immense gap between screening and treatment. Postpartum women--particularly low-income mothers and mothers of color--obtain treatment for postpartum mood and anxiety disorders at abysmally low rates, even after they've been positively screened. 

Why?

• stigma, fear of judgment
• lack of or inadequate health insurance, high copays, high deductibles
• few trained perinatal providers in many areas
• time constraints and difficulty securing childcare 
• experiences of discrimination within the medical system

Efforts like the community health center pilot program in Massachusetts that embeds comprehensive postpartum support within community health centers both increase screening rates and address these barriers to treatment. More innovative community-based programs are needed to bridge the gap between screening and treatment for perinatal mood and anxiety disorders. 

There's also a little fact in the original research about the oxytocin receptor that's interesting. The study found that there was no connection between the oxytocin receptor and risk for PPD in women who had depression during pregnancy - the link was only in women who were not depressed prenatally. Not only does depression in pregnancy increase the risk for postpartum depression, but untreated prenatal depression is also a risk factor for unfavorable pregnancy outcomes including low-birth weights and pre-term births. So, we still need to screen all pregnant women AND treat those who are depressed. 

The Massachusetts legislature overturned the Governor's veto of funding for the pilot program I mentioned above.  I've been asking many of you in Massachusetts to contact your legislators about this recently, so thank you for all your advocacy!

Meanwhile, Congresswoman Katherine Clark and Congressman Ryan Costello introduced legislation, the Bringing Postpartum Depression Out of the Shadows Act, to increase and improve screening AND treatment for women with postpartum depression through grants to the states to develop new programs. 

What's caught your eye in the news lately related  to pregnancy or postpartum emotional complications? 

In Boston, we're lucky enough to have the Center for Women's Health at Massachusetts General Hospital. Not only do they conduct and disseminate information about the latest perinatal research, but they offer consultations for pregnant and postpartum women.

They recently had a look back of important posts on the blog from 2014, including their excellent response to the NY Times article on SSRI use during pregnancy. 

There are some great speakers lined up including Dr. Gold, a pediatrician; Jamie Zahlaway Belsito, a postpartum depression survivor; Dr. Byatt, the Medical Director of MCPAP for Moms; Liz Friedman of MotherWoman; and Divya Kumar, a driving force behind a pilot project that put a postpartum doula in a community health center to provide accessible care, screening for perinatal emotional complications, and connection to clinicians for mothers there for their own or their children's medical appointments. 

I'm hopeful that it will be an energizing afternoon where legislators can better understand the resources available - and not available - across the state, where mothers and families can meet with their representatives and providers there, and where more connections among us all can be made. 

I'll be there most of the afternoon at the PSI of MA table. Please come by and say hello!

For the first time mother, a new moms group can be an anchor during long days of on-demand feedings and unpredictable naps. It's a commitment outside the house. No one cares if there's spit up on the baby's (or your) outfit. And you can find reassurance that others are going through the same challenges, while hearing from the experienced moms of babies a few months older that it does in fact get better - or at least change. Groups combat the stir-crazy.  

When your mind immediately imagines getting into an accident every time you put your baby in his car seat; when the pure physical ache of grief floods you each time you try to stand up; when you are facing yet another roller coaster month of hope and despair and anger; when you can't stop yourself from yelling at your child you can feel enveloped in a fog of isolation. 

For these individuals dealing with postpartum emotional complications, loss, infertility, parenting challenges—and so many more issues—a support group can be a lifeline.

The mere act of being in a room with others fights that isolation. In a group, you hear that others have said/thought/felt/done similar things. They nod, they pass the tissues, they laugh with you, and their eyes tear up because they recognize your story. Sometimes you have the perfect resource or a "been there done that" to share that helps someone else. Sometimes you just want to go to report a great success. You can leave a support group more confident, less alone, with a tiny bit less stress, with an idea to implement, simply lighter after a good cry or a vent or a laugh. You can find solace in a group. 

Resources: 

• For a group addressing postpartum depression, anxiety, or adjustment challenges, Postpartum Support International can be a good place to find a group in your state. 
  
• Resolve offers infertility support groups nationally.
• For pregnancy and infant loss support groups, Share has chapters in most states. In Massachusetts, Hopeful Connections, also lists groups across the state. 
• Parents Helping Parents of Massachusetts offers parent support groups to "express frustrations and concerns about their children and families and get advice from other parents who understand."
• For information about the groups I'm currently running, look here. 

Last weekend, I was at a workshop with Bo Forbes entitled "Yoga for Emotional Balance: Simple Practices to Help Relieve Anxiety & Depression." To be honest, I'm not entirely sure yet what and how I might incorporate the workshop into my own life and into my clinical practice, but I wanted to share some initial thoughts.

There were some ideas which seemed relatively straightforward:

• Restorative yoga poses (poses in which your body is supported with props like blankets and bolsters and held for a long time) and breathing can calm the nervous system and soothe an agitated mind. 
• Checking in with your body and learning how to tune in to your thoughts, physical sensations, current emotional landscape, and energy level is a valuable -- if sometimes difficult -- practice. Doing this provides an opportunity notice how we are doing in the moment, a way to measure changes, and a chance for self-compassion. 
• These mindfulness practices also assist us to stay in the moment, rather than mulling over the past or worrying about the future, hallmarks of depression and anxiety. 

These ideas fit with my frameworks for depression, anxiety, trauma, and the nervous systems. And they seem relatively accessible to share with the women, men, and adolescents with whom I work. Certainly any practice that encourages people to inhabit their body with conscious and compassionate attention is beneficial - especially when I think about women who've experienced birth traumas or losses, clients with chronic pain, or adolescents with body image struggles. 

Other aspects of the training elicited more bewildering discomfort. But to paraphrase Forbes: awkward is good; awkward is where the learning happens. So, I'm still mulling over interoception (briefly, this means the sense of the physiological condition of the body), the enteric nervous system in the gut, and how shifting visceral (or, body-based) resilience to change through slow, deliberate movement actually affects emotional resilience. 

I'm excited to integrate some of these concepts in my learning and practice. I think that there are also some valuable connections to make with new research about the role of inflammation, depression, and the consequences for perinatal mental health. And I'm feeling quite grateful for the opportunities that I have to go and take workshops outside my comfort zone and learn from other communities! 

Here's a quick little video of Bo Forbes talking about the nervous system - not from the training I went to, but it gives a sense of her framework. 

I'd love to hear your thoughts in the comments, particularly if you're a clinician incorporating more body-based interventions in your practice. 

On 6/16/14, the NY Times published two articles on maternal mental health. This was above the fold, front-page media coverage for the emotional complications that mothers face. Let's talk about the cover story: 'Thinking of Ways to Harm Her': New Findings on Timing and Range of Maternal Mental Illness.

First, a quick point about language. I don’t love that the headline led with the attention-grabbing reference to intrusive thoughts of harming a baby. And the article fell into the pattern of referencing either “postpartum depression,” which it makes the point of saying doesn’t accurately encompass the range of experiences, or “maternal mental illness,” which can come across as very medical. But the alternatives, like "perinatal mood disorders" or "emotional complications" have their limitations as well. So, I try to use a range to best speak to women's experiences. But back to the article...

Women and families shared their experiences with depression, intrusive thoughts, and anxiety, demonstrating incredible vulnerability and courage. Writer Pam Belluck discussed the new research that backs up what clinical experience tells us: that emotional complications often start in pregnancy and are not easily identified as "just” depression, but frequently include overlapping features of depression, anxiety, obsessive compulsive disorder, and bipolar disorders. She touched on some of the factors that are associated with these experiences, the prevalence, and the range in timing when symptoms arise (during pregnancy and throughout the postpartum year). And there was mention of treatment: medications, therapy, support groups, and help to address impacts on bonding and attachment, though I wish there was more exploration of what treatment looks like for women and families. 

Belluck highlighted efforts to increase screening for postpartum mood disorders and the frustrating fact that more screening does not necessarily mean improved health: "A study in New Jersey of poor women on Medicaid found that required screening has not resulted in more women being treated...the law educated pediatricians and obstetricians, but did not compensate them for screening." 

In Massachusetts
I am thankful that in Massachusetts we are taking some steps to increase screening. A 2010 law authorized the Department of Public Health to "develop a culture of awareness, de-stigmatization, and screening for perinatal depression." But changing a culture and eliminating stigma take time. 

Even if they are given a questionnaire, new moms often hide the truth of how they're feeling from their doctors and pediatricians out of shame and fear of judgment. And an OB who sees a woman for a mere 15 minute follow up appointment at 2 or 6 weeks postpartum may feel reluctant to ask further questions because they're unsure of where or to whom they would even refer her. The Massachusetts Child Psychiatry Access Project (MCPAP) aims to address some of these barriers by expanding its focus to include maternal mental health. Starting next month, doctors will be able to call a toll-free number to speak to a care coordinator to help find a mental health provider for their patient. 

MCPAP for Moms will be a great resource for doctors, but what about for mothers, their partners and families, and other providers? Granted there are some resources like the Massachusetts Postpartum Support International warmline (866-472-1897) and regional and community task forces creating systems of care for maternal mental health, but there are still gaping cracks women and families can fall through. 

What I’m most hopeful about in Massachusetts is a relatively small pilot project focused on preventing postpartum depression by putting postpartum doulas who can provide support and screenings in a few community health centers. A friend and colleague, Divya Kumar, Sc.M., is a certified postpartum doula and certified lactation counselor who works in one of these community health centers. Excited about the integration of services to address maternal health, Kumar says, “We need to change the way we do this...it's not just about preventing postpartum depression, but it's about promoting postpartum wellness and overall emotional health in new moms.” When a new mom brings her baby in for his well baby visit, Kumar is able to spend time with her helping with breastfeeding challenges, screen her for postpartum depression, and if needed, refer her to the mental health clinician down the hall who can see her that same day. And this is true even if the mother is not a patient of the health center. 

Plus, the community health center has midwives who also provide prenatal care so there’s the possibility for connection during pregnancy – important for the women who experience depression and anxiety during pregnancy and/or those who have a known mental health history. 

"Timely screening for perinatal emotional complications can save lives—especially in a community health center lucky enough to have comprehensive postpartum support AND mental health services right under one roof. [I am] so thankful for this pilot money and for centralized, accessible services," says Kumar, "We are offering services to families where the baby is seen at the clinic even if mom is not...We have caught a couple cases of PPD that way--huge, huge victories!"

Until this pilot project can be replicated to reach more women, a woman (or someone in her family) needs the knowledge to recognize that what she's feeling isn't just new mom exhaustion, the courage to ask for help, and the resources to be able to find/afford/get to treatment. On top of all that, treatment must be specialized, connected to community-based supports, and welcoming. Dr. Kozhimannil, quoted in the article, speaks to the barriers: "There are also not enough treatment options…If a woman comes with a baby, and it’s a place treating people with substance abuse or severe mental illness, she may be uncomfortable.” (And yet, let's not forget that these are not mutually exclusive groups). 

When everything falls into place, it works. Timely, accessible treatment can help. As Jeanne Marie Johnson was quoted saying, once she received help, “It’s just a whole world of difference.” 

When I was looking for my office space, I thought about what it would be like for pregnant or new moms coming to see me. I looked for an office with an elevator, easy bathroom access, and parking. A chair that rocks for a breastfeeding mother, a hidden box of toys to distract an infant, water or a cup of tea to offer some comfort and hydration: these are all small ways I hope that the environment welcomes pregnant women and new mothers. And my connections to other resources—psychiatrists, acupuncturists, sleep consultants, lactation counselors, groups—form the foundation of a potential community of support for isolated new mothers and families.

Ultimately, national media coverage of perinatal emotional complications like these NY Times articles helps to decrease isolation and stigma. I hope that this leads to more screening, more treatment, and more health for mothers and families. A bow of gratitude to the women who shared their stories and to Pam Belluck for writing these pieces.

What's your take on the article? Please share in the comments.