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Every Day Should Be Maternal Mental Health Awareness Day! What Educators Need To Know!

May 27th, 2014 by avatar

Friday_may_campaignMay is Maternal Mental Health Awareness month, when agencies on the local, state and federal level along with private and public organizations promote campaigns designed to increase awareness of perinatal mood disorders.   While it is good to increase awareness of the symptoms, sources of help, treatment options and impact of perinatal mood disorders on parents, families and communities during the month of May, the focus really needs to be 365 days a year!  Over 4 million babies are born every year in the USA.  Pregnancy and birth happen every single day to women and families.  Perinatal mood disorders affect women and their families every single day!

Recently, the tragic death of three young children in Torrence, CA was in the news and the children’s mother was arrested on suspicion of murdering her three daughters.  While many details have yet to be made public, this was a new mother  whose youngest child was just two months old.  This woman may have been experiencing a crisis as a result of a postpartum mood or anxiety disorder (PPMAD).

Take this quick ten question quiz and test your knowledge of perinatal mood disorders.  Then read on to find out more and what you can do to help the families that you work with.

While PPMAD can affect a mother during pregnancy or the first year postpartum, there are some risk factors that may increase the likelihood of a woman experiencing this complication:

The above list is from the resource: Postpartum Progress

There is a wonderful three minute video from the 2020 Mom Project that explains more about why so many women are not receiving the help they need. This video was released by the National Coalition for Maternal Mental Health. We do not have the infrastructure in place that screens every woman or enough skilled providers who can recognize the symptoms and provide or refer to suitable treatment options.

Some typical (but not all inclusive) symptoms of Postpartum Mood and Anxiety Disorders

  • Are you feeling sad or depressed?
  • Do you feel more irritable or angry with those around you?
  • Are you having difficulty bonding with your baby?
  • Do you feel anxious or panicky?
  • Are you having problems with eating or sleeping?
  • Are you having upsetting thoughts that you can’t get out
  • of your mind?
  • Do you feel as if you are “out of control” or “going crazy”?
  • Do you feel like you never should have become a mother?
  • Are you worried that you might hurt your baby or yourself?

Childbirth educators and others who work with women during the childbearing year have a responsibility to discuss, share, educate and provide resources to all the families they work with.  Ignorance is not bliss, and the more we discuss the symptoms, risk factors and resources that are available to help families in need with those we have contact with, the fewer women will suffer in silence and go without the help they need.

Resources for Women and PartnersPostpartum Progress

 Postpartum Psychosis Symptoms (in Plain Mama English)

Postpartum Support International 1-800-944-4PPD

 National Suicide Prevention Lifeline 1-800-273-TALK

Mother to Baby (formerly OTIS)

Medications & More During Pregnancy & Breastfeeding.

(866) 626-6847

Text-4-Baby Health Info Links

How do you talk about perinatal mood and anxiety disorders in your classes?  What activities do you do to convey this information effectively?  Do you bring up this topic again at the childbirth class reunions you attend?  Can you share what works well for you so that we can all learn?  What have your experiences been in helping women and their partners to be knowledgeable and informed? What do you do to be sure that every day is Maternal Mental Health Awareness Day?

 

Babies, Birth Trauma, Breastfeeding, Childbirth Education, Depression, Infant Attachment, Maternal Mental Health, Paternal Postnatal Depression, Perinatal Mood Disorders, Postpartum Depression , , , , , , , , , ,

Don’t Ever Give Up! An Interview with Katherine L Wisner, M.D., M.S. American Women In Science Award Recipient

April 30th, 2013 by avatar

“Childbirth educators are crucial front-line professionals in providing information to women about their risks for medical complications related to pregnancy and birth, and postpartum depression is a common problem.” – Dr. Katherine L Wisner

Katherine L. Wisner, M.D., M.S., has been involved in clinical work and research since the mid-1980′s. Prior to her medical training, she achieved a Master’s Degree in Nutrition. Dr. Wisner did a pediatrics internship, is board-certified in both adult and child psychiatry, and completed a 3-year postdoctoral training program (NIAAA-funded) in epidemiology. Her major interest area is women’s health across the life cycle with a particular focus on childbearing. In January 2011, Dr. Wisner was chosen as the recipient of AMWA’s Women in Science Award for the year 2011. Dr. Wisner is a Norman and Helen Asher Professor of Psychiatry and Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine.

Most recently, Dr. Wisner and colleagues (2013) published the largest American study to date (N = 10,000) investigating the value of screening for depression in postpartum period (4 to 6 weeks) using the Edinburgh Postnatal Depression Scale (EPDS)1

I know I speak for all in welcoming Dr. Wisner to Science and Sensibility.

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Walker Karraa: Congratulations to you and your colleagues on this most recent JAMA Psychiatry study. The findings have significant implications regarding the value of screening for postpartum mood and anxiety disorders. What role do you think childbirth education has in the area of perinatal mental health?

Dr. Wisner: Childbirth educators are crucial front-line professionals in providing information to women about their risks for medical complications related to pregnancy and birth, and postpartum depression is a common problem.  

WK: Should childbirth educators and doulas be trained to screen for PMADs? 

Dr. Wisner: My answer would be yes, but the controversy in the field is about routine screening – that women with depression can be identified, but getting them to mental health treatment if it exists outside the obstetrical care setting is difficult.  So the counterpoint is– why screen if we don’t have on-site, accessible, acceptable services for mental health?  My opinion is that we ought to work toward this model of integrated care rather than decide not to screen!   I certainly think childbirth educators and doulas can increase education and awareness and are often the first professionals that women call for help, so that group of women who want to and can access care can get the help they need.

WK: How could childbirth education organizations use this study to inform their practices and curriculum?

Dr. Wisner:The study provides evidence that the prevalence of depression is high both during and after pregnancy and evidence that screening is effective in identifying women with major mood disorders.  Women with psychiatric episodes certainly can be assured that they are not alone, which is a common belief of pregnant women and new mothers.  

WK: Due to the prevalence of self-harm ideation in postpartum period found in your study and other studies supporting this alarming rate, and the fact that suicide is the second leading cause of maternal death, how might childbirth education organizations and professionals address this critical problem?

Dr. Wisner:Screening with the EPDS, which has the item 10 self-harm assessment questions, and sensitive exploration of self-harm and suicidal ideation is the primary approach to suicide prevention.  It has to be identified before intervention can occur.  

WK: A remarkable finding in your study was the rate of bipolar disorder among women who had screened positive (10 or higher) on the EPDS. Additionally, among those with unipolar depression, there was high comorbidity for anxiety disorders. What are your thoughts as to how childbirth education might begin to help childbearing women unpack and understand the symptoms of anxiety in prenatal education?

Dr. Wisner: In our study we found that women with depression usually had an anxiety disorder that pre-dated the depressive episodes—this observation is true for women who are not childbearing as well.  Having anxiety or depression as a child or adolescent increases the risk for peripartum episodes.  There are excellent pamphlets and websites about perinatal depression (www.womensmentalhealth.org; www.postpartum.net) which can be used to frame a brief discussion and give to the patient for reference.  This also gives the message that talking about mental health before and during childbearing is an important topic, just like surgical births, anesthesia etc.    

WK: The data you have contributed to science are unsurpassed, yet early in your career many questioned whether postpartum depression was real, and doubted if you would be able to pursue a research career in postpartum mood disorders.

Dr. Wisner: Indeed!

WK: How did you persevere–and particularly in a male-dominated field?

Dr. Wisner: I got angry that so few data were available to drive care for pregnant and postpartum women and never let go of the importance of obtaining that information.  That motivation was coupled with a real joy in taking care of perinatal women and their beautiful babies!  

WK: Do you think there is still an underlying doubt as to whether postpartum depression (or perinatal mood/anxiety disorders) is real?

Dr. Wisner: Not in academic medicine, and I have not heard anyone say this in about a decade (thankfully!). 

WK: What is your favorite part of the research? Data collection, analysis, or interpretation?

Dr. Wisner: Publishing findings that make a difference in women’s lives, and holding the babies. 

WK: What new trends do you see in research as hopeful signs of progress?  

Dr. Wisner:  The incredible number of young clinicians and investigators who are interested in perinatal mental health.  Also,  our field has been so accepting of interdisciplinary enrichment of research questions.  

WK: What advice would you share with women in research today? 

Dr. Wisner: Network with  your colleagues inside and outside your organization frequently, attend perinatal mental health meetings and don’t ever give up!  

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What are your thoughts regarding Dr. Wisner’s expert opinion?   How do you currently address postpartum depression and anxiety in your childbirth classes?  After reading this interview and taking at look at Dr. Wisner’s just published research, might you reconsider how you teach about this important topic or change your approach?  Let us know in the comments section below- Sharon Muza, Community Manager

More about Dr. Wisner

Dr. Wisner’s research has been NIMH funded since she completed her post-doctoral training in 1988. She served on NIMH grant review sections continuously from 1994 to the present. Dr. Wisner completed was a founding member of the NIMH Data Safety and Monitoring Board, and is only the second American to be elected President of the Marce International Society for the study of Childbearing Related Disorders.

Her major interest area is women’s health across the life cycle with a particular focus on childbearing. She is a pioneer in the development of strategies to distinguish the effects (during pregnancy) of mental illness from medications used to treat it (Wisner et al,JAMA 282:1264-1269, 1999; MHR01-60335, Antidepressant Use During Pregnancy).

In recognition of her work, she was a participant in activities related to the FDA Committee to Revise Drug Labeling in Pregnancy and Lactation, a committee member for the National Children’s Study (Stress in Pregnancy), a consultant to the CDC Safe Motherhood Initiative and the Agency for Healthcare Research and Quality Report Perinatal Depression: Prevalence, Screening Accuracy and Screening Outcomes.

Dr. Wisner was elected to membership in the American College of Neuropsychopharmacology in 2005. She received the Dr. Robert L. Thompson Award for Community Service from Healthy Start, Inc., of Pittsburgh in 2006 and the Pennsylvania Perinatal Partnership Service Award in 2007 from the State of Pennsylvania. 

Dr. Wisner was the first American psychiatrist to collect serum from mothers and their breastfed infants for antidepressant quantitation as a technique to monitor possible infant toxicity. She published the only two placebo-controlled randomized drug trials for the prevention of recurrent postpartum depression and showed that a serotonin selective reuptake inhibitor was efficacious.

References 

1.Wisner, K.L., Sit, D., McShea, M. C., Rizzo, D.M., Zoretich, R.A., Hughes, C.L., Eng, H.F., Luther, J.F., Wisneiweski, S. R., Costantino, M.L., Confer, A.L., Moses-Kolko, E.L., Famy, C. S., & Hanusa, B.H. (2013). Onset timing, thoughts of self-harm, and diagnoses in postpartum women with screen-positive depression findings. JAMA Psychiatry, Published online March 13, 2013. Doi: 10.1001/jamapsychiatry.2013.87

 

Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Maternal Mental Health, New Research, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research , , , , , , , , ,

EMDR Part Three: Listening to Women; Personal Experiences of EMDR for Treating PTSD

February 28th, 2013 by avatar

In this series about EMDR (Eye Movement Desensitization and Reprocessing), Part One looked at qualitative research evaluating EMDR as treatment for post-traumatic stress disorder (childbirth onset). In Part Two, EMDR clinicians weighed in on their feelings about the safety of EMDR during pregnancy. When those EMDR posts were published, I received a lot of behind the scenes feedback from women who either loved or hated their experiences with EMDR; there didn’t seem to be a middle ground!

Women Thrive When They Learn Emotional Skills Istock/GoldenKB

I felt these women’s voices need to be heard (many thanks to Sharon Muza, S&S Community Manager, for her gracious agreement!) The results are here: four interviews conducted with four real women who suffered from trauma in the perinatal period and tried EMDR.

It’s unfortunate these lovely women suffered extreme emotional turmoil at such an important time in their life; when they were working and hoping to build their emergent family and when they were primarily responsible for the safety and care of their infants.

Through sharing their stories, all women indicated to me that they hope that their voices will contribute to the collective movement to incorporate mental health care into the overall care of women and their families in the childbearing year.

Characteristics of Their Trauma

All of the women interviewed experienced trauma in the early postpartum period. Three suffered specifically from birth trauma; all experienced a severe perinatal mood disorder. Three of the women additionally were coping with complex, long-term, multi-layered emotional trauma, stemming back to abuse in childhood.

All of the women interviewed were seeing licensed therapists who incorporated EMDR into their overall treatment plan for trauma. Some asked to have their identities masked, so identifying details and names are obscured, but the overall personal statements and feelings are preserved.

They are empowering to all of us in that ALL of them valued their mental health and were brave enough to seek professional help!

Personal Healing Processes

The women interviewed are all emotionally mature adults. They’re aware of their life situations and the impact of trauma on their well-being. They’ve worked hard to explore and develop life-long skills and methods of managing their emotions. Thus, these are all women who are proactive, sophisticated and intelligent about their emotional healing processes. Before they used EMDR, all of the women had already incorporated many forms of healing into their personal self-care plans.

Their self-care plans included: long-term psychotherapy, journaling, expressive therapies such as art, music and movement, yoga, exercising, gardening, cognitive behavioral therapy, goal setting and medication. One woman indicated she was in so much pain from long-term, severe, past abuse she had seriously discussed electroconsulsive therapy with her psychiatrist. So, when their trusted therapists suggested trying EMDR, specifically designed to treat trauma, all the women agreed.

Personal Perinatal Traumatic Events:

In their own words, the women share their individualized, personal perinatal trauma experiences below.

Birth Trauma:

Kim (not her real name) shares her traumatic birth story:

“My son was born after an easy pregnancy but a complicated birth. I’d very nearly had a vaginal birth; the nurses could see the top of his head, but it was turning to the side each time I pushed. After nearly 2 hours of this, I underwent a c-section because I had spiked a fever and things were not progressing. During my c-section, I was overcome by anxiety and completely paralyzed by fear.

I literally thought I was dying as my son was being born, yet due to the panic, I was unable to verbalize this fear to anyone.

I spent that time shaking and having what I thought were my last panicked thoughts and breaths. It was the the most afraid I’ve ever been in my entire life, and also the most alone I’d felt, despite being surrounded by others.

After the surgery, I wasn’t able to hold my son for 3 hours. I spent the time in recovery, scared that something were wrong and nobody was telling me. I am still not sure of the reason for the delay.

My maternity leave felt long, due to postpartum anxiety and depression and a baby who barely slept and I cried nonstop some days. I felt like a terrible mother who was unable to console her child or enjoy him. I felt tremendous guilt. In addition to the emotional aspects, my c-section scar was not healing properly, so I felt as if I were constantly making a 30-mile trek (newborn in tow) to my ob-gyn’s office for checkups. “

Birth Trauma Layered on Childhood Trauma:

Karen (not her real name) said:

“My very traumatic birth triggered already active memories of severe childhood abuse, parental suicidal attempts in front of me, active alcoholism & substance abuse in the family and severe childhood neglect.”

Helen (not her real name) said:

“I was working on birth trauma at the start of the EMDR, but later on, abuse, illnesses, and marital distress. I was mainly focused on the birth trauma I had experienced when I used EMDR.”

Postpartum Traumatic Event Layered on Childhood Trauma:

Jessica Banas explained her perinatal trauma as such:

“I was traumatized by my childhood with my father. He was very emotionally abusive. Seeing him overdose (on a drug called GHB) the first night my parents were to supposed to have been watching my infant son for me, so I could rest, felt like the ultimate betrayal. Once again, not only were they NOT there for ME, but I had to SAVE them (again) instead!!!”

Women’s Experiences Show Us Moms with PTSD Suffer Co-morbid Perinatal Depression & Anxiety

It is fascinating and sad that all three women with pre-existing trauma stated their prior trauma was re-triggered by a perinatal traumatic event (traumatic birth or other traumatic event postpartum). And all four suffered from severe postpartum depression and anxiety after their traumatic perinatal event. A woman’s mental health is an important aspect of the childbearing year.

As discussed in a previous blog post, one in four women suffers depression at some point in her life, and women are more likely to suffer depression during and shortly after pregnancy than at any other time (Nonacs, 2006). Ruta Nonacs, MD (2011), editor-in-chief of Massachusetts General Hospital’s Center of Women’s Mental Health’s website estimates annually in the US, there are about 4 million births, and about 950,000 to 1,000,000 mothers suffer from depression either during or after childbirth every year. 

Having a personal history of a mental illness in her lifetime, such as depression, anxiety, PTS/PTSD, OCD or bipolar disorder (remember, this is whether it was diagnosed & treated or undiagnosed & untreated) increases a woman’s risk of postpartum depression. A previous history of previous postpartum depression increases a woman’s risk of a recurrence to 50 – 80 % risk of recurrent PPD, as compared to a 10- 20% risk factor without having had a prior episode.

It’s important to note that the women’s constellation of PTSD symptoms intensified and they developed severe postpartum depression and anxiety.

Jessica eloquently states how important women’s mental health is to the postpartum period:

” One important symptom of my PTSD that complicated and worsened my PPD was when my infant son would cry and interrupt my ruminations of my father Od-ing. I’d get angry….that would trigger thoughts of wanting to harm my son and cause me great anxiety and incredible guilt…..there were many times I was too afraid if I went to tend to him, I’d treat him harshly, or hurt him This created such a sense of worthlessness and shame, I thought of suicide one night. Instead, I told my husband and we reached out and got help.

It is a very important aspect of PTSD in that I am personally aware how detrimental it is on PPD. My PPD rapidly escalated after getting PTSD. And one seemed to feed on the other. Getting treated for BOTH issues was very important.”

Women’s Experiences Show Us the EMDR Outcomes

Two very positive experiences

Kim’s Experience with Traumatic Birth & Postpartum Anxiety & EMDR

Kim, who suffered from birth trauma and postpartum anxiety, had a positive experience with EMDR. Here is her story of healing.

Kim said that her therapist incorporated EMDR into her current psychotherapy sessions. She said she hadn’t realized that she’d been suffering with PTSD until almost a year after the incident. She says she discovered her anxiety was stemming from a traumatic birth experience at a therapy session:

Kim says:

“…of course I’d had PTSD from thinking I was dying while my son was being born! My anxiety, which had a lot to do with waiting for something terrible to happen to me or my son, started to make sense in light of this new revelation.”

Kim experienced the EMDR itself as calming. She held tappers in her hands while her therapist led her through visualizations. Her therapist warned her that EMDR could be emotionally triggering and if she needed to call her, she was welcome to do so. And it was triggering for Kim. After her first session, she suffered from an anxiety attack and had to call her therapist, and received the help she needed.

Ultimately, Kim’s overall experience with EMDR was emotionally freeing and healing.

She goes on to say:

“Up until the EMDR, I was unable to speak about my c-section at all. I couldn’t see anything related to the birth experience (with or without c-sections involved) on television, either. If I caught a glimpse of a birth on TV, I cried. I had a lot of anxiety on the few occasions I tried to watch A Baby Story on TLC, as a test to see how I felt watching another woman’s experience.

After EMDR a few times, I became more comfortable thinking about and processing my experience, and even eventually talking about it with others. I no longer viewed my scar as something horrible and ugly. Having EMDR gave me back my confidence because it helped me stop seeing myself as a failure (because I needed a c-section instead of birthing vaginally). “

Kim would recommend EMDR to another person trying to recover from trauma, but with some warnings about the emotional response.

Jessica’s Experience of Postpartum Traumatic Event, PPD, Suicidal Ideation & EMDR

Jessica, who experienced the trauma of her father’s overdose while her parents were supposed to be watching her baby, had a positive experience with EMDR. Here is her story of healing:

Jessica said that her therapist incorporated EMDR into her current psychotherapy sessions. Her therapist suggested she try something “new” that would remove the sting of the trauma from her mind. Jessica was skeptical but thought she’d give it a try.

Jessica says:

“The EMDR was pretty much wrapped around by talk therapy in that we’d start out by talking and end up by talking… EMDR took the emotional ties from the traumatic memories away. I no longer find myself reliving any of those memories that were treated with EMDR. I no longer feel any emotional pain from the OD event. I have no loss of sleep, anger, depression, or any anxiety over that event.”

Jessica says she did not find the EMDR emotionally triggering at all, but many childhood memories came flooding back. .

“Not at all…frankly, I thought it was lame at first (wiggling a finger in my face? REALLY?) and had no hope it would have ANY effect at all. Once we (quickly) healed the OD trauma, memories from my childhood did come flooding back! I found that to be very interesting! Fortunately, my childhood was not as terrible as many, so I could handle this phenomenon.”

Jessica recommends EMDR:

“…as long as the person is seeing a well trained, compassionate therapist! EMDR helped me and I have gone on to suggest it to other people who were in pain as I was….those people have been healed by EMDR as well….I find it a useful treatment and extremely non-invasive compared to other treatments!!”

Two very negative experiences

Karen’s Experience with Birth Trauma, Past Trauma, PPD, PPA & EMDR

“My experience was physical and emotional and in both cases negative. I felt physically ill, vertigo, nausea. Disorientation, short-term memory loss, headache. Emotionally, it was detrimental as it brought up my most difficult trauma and I felt completely triggered. I tried to hang in there with the process, but only did a few sessions. The EMDR sessions were not processed with in-between traditional talk therapy sessions. The EMDR made my symptoms worse, my anxiety worse, and the neurological side-effects were horrible. While my therapist did a wonderful job at regrouping,  after we decided to stop doing it, I actually went up on my medications and saw her 2x a week for a while. It was just too much. What I think had happened to me was more resurfacing of old memories that I had compartmentalized in years of talk therapy and medication. I actually think I needed a medication adjustment when I was so desperate for relief. “

Karen would not personally recommend EMDR to another.

Helen’s Experience with Birth Trauma, Past Trauma, Postpartum Mental Health Complications & EMDR

“My therapist suggested the EMDR may be helpful for both traumas (birth and childhood). I had 6 sessions that were each an hour long. Some of this process was also traditional talk therapy in between the EMDR. I found EMDR not helpful in treating my traumas.”

“It was extremely triggering and the therapist pushed me into a lot of it. She would try to help me regroup by taking deep breaths and little breaks in between. But I always felt drained after each session and even more triggered with PTSD.”

Helen would not recommend EMDR for another person:

“I do not think I would personally recommend EMDR to another person for a trauma. I believe the therapist shoved me into it too soon and left me for days swirling in the emotions of that. I have heard it can be wonderful and healing for others. For me, it triggered too much to soon and my experienced left me more traumatized. I can’t think of those (EMDR) coping skills and techniques without feeling overwhelmed with memories.” 

Conclusions

As we can see from real women’s experiences, EMDR was extremely triggering to two of the women, but resolved emotional distress well for the two other women. Again we are reminded that one size does not fit all when it comes to treating mental health.

The women’s experiences indicated that when working with EMDR for trauma, even experienced and trusted therapists encountered strong triggering responses in their clients. In these instances, these therapists needed to know how to appropriately re-group and therapeutically support their clients either in the session and/or be appropriately available outside of scheduled sessions.

It was not appropriate for a therapist to urge a client to try or keep using EMDR if the client did not really want to, or if the client was having an overall non-therapeutic effect.

As we can see from these real women’s experiences, the treatment of post-traumatic stress has the potential to be devastating to the client as far as awakening or re-triggering compartmentalized past emotional distress.

In this small article and small example, it is interesting to me that the four women who volunteered to share their stories in this small had extreme reactions to EMDR, none neutral. These results reinforce my usual conservative approach to managing emotional distress, that is, if one is suffering from debilitating mental and emotional distress, it is best to consult with a licensed professional.

What I find empowering about these interviews is that ALL of these women VALUED their mental health and were brave enough to seek help. Fight the stigma! Don’t be afraid to get help!

Author’s Note: None of these women were or are my clients. I sought out non-clients for the purpose of these interviews.

References

Nonacs, R. (2006). A deeper shade of blue. New York: Simon and Schuster.

Birth Trauma, Cesarean Birth, Childbirth Education, Depression, Do No Harm, EMDR, Evidence Based Medicine, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, Pregnancy Complications, PTSD, Research, Trauma work , , , , , , , ,

Professional Perspectives Part III: Advocacy, Postpartum Doulas and Childbirth Education

December 13th, 2012 by avatar

By: Walker Karraa

Regular contributor Walker Karraa has written an excellent three part series on Perinatal Mood and Anxiety Disorders (PMAD) and what the childbirth educator or birth professional can do to help women get the help they may need when dealing with mental illness during the prenatal and postpartum period.  Walker interviews experts in the field who all offer concrete steps, activities and resources so that educators and others can do to be more prepared to discuss this important subject with students and clients.  Today, Walker interviews Jennifer Moyer, an expert in the field of postpartum psychosis who is an active mental health advocate, and has had personal experience with postpartum psychosis after her son’s birth. Here you can find Part I and Part II of the series.– Sharon Muza, Community Manager.

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“Childbirth professionals have a unique opportunity to reach a tremendous number of women and families as most pregnant women participate in some type of childbirth class.” —Jennifer Moyer


 

http://flic.kr/p/Tx5rm

As many of you know, I am a big proponent of qualitative research methods. The lived experience of a phenomenon offers a depth of data that objectivist methods simply cannot collect. Researchers in women’s reproductive health have been on the forefront of the understanding and implementation of research that listens to mothers. In the same way, I wanted to offer Science and Sensibility readers the voice of a mother, postpartum doula, and advocate who has lived it—experienced postpartum psychosis (PP) and not only “survived”, but transformed the adversity into a path to helping others.

Jennifer Moyer has unique insight into mental health as a recovered mom herself. She overcame postpartum psychosis, a life threatening mental illness, which she was struck with when her son was eight weeks old. She has focused her efforts on being a mental health advocate in the area of perinatal mental health in order to help others experiencing mental illness related to childbearing.

Jennifer also has experience as a postpartum support and education consultant, a certified postpartum doula and a speaker on mental health issues.

WK: The recent Felicia Boots tragedy in the UK has brought media attention to the dangers of untreated perinatal mood disorders, specifically postpartum psychosis (PP). What are your thoughts as to the multiple factors that contribute to a tragedy such as this? 

Jennifer Moyer: I believe there are several factors that contribute to tragedies associated with perinatal mood disorders.  One of the factors is the ignorance about the difference between postpartum depression and postpartum psychosis, which is usually the disorder associated with infanticide.  In my experience with postpartum psychosis, I was completely unaware that postpartum psychosis even existed despite having an educated and proactive pregnancy.  I think many mothers are in the same situation.

Another contributing factor is that providers often do not provide education on the warning signs or risk factors of perinatal mood disorders making it difficult for a mother or her loved ones to recognize what is happening.  Of course the lack of preventative screening also causes a mother at risk from receiving early intervention.

There are other factors as well but I believe these are the primary obstacles contributing to unnecessary tragedies.

WK: Can you describe the sequelae of postpartum psychosis (PP)? 

Jennifer Moyer: An aftereffect or secondary result of postpartum psychosis is different for each mother but, in general, I have found that it changes the mother forever.  In my case, postpartum psychosis came on sudden and unexpectedly.  Once I was stabilized, the trauma I had experienced prior to my diagnosis left me with serious post-traumatic stress.  It also shattered the positive and strong bond I had with my son prior to the onset of postpartum psychosis.  It caused me to question my ability has a mother for a very long time.  The lack of understanding about my condition as well as lack of support from someone, who had experienced postpartum psychosis, lengthened my recovery and made it much more difficult.

Postpartum PsychosisPostpartum Psychosis is a rare illness, compared to the rates of postpartum depression or anxiety. It occurs in approximately 1 to 2 out of every 1,000 deliveries, or approximately .1% of births. The onset is usually sudden, most often within the first 4 weeks postpartum.Symptoms of postpartum psychosis can include:

  • Delusions or strange beliefs
  • Hallucinations (seeing or hearing things that aren’t there)
  • Feeling very irritated
  • Hyperactivity
  • Decreased need for or inability to sleep
  • Paranoia and suspiciousness
  • Rapid mood swings
  • Difficulty communicating at times

The most significant risk factors for postpartum psychosis are a personal or family history of bipolar disorder, or a previous psychotic episode.

source: Postpartum Support International

WK: How might childbirth professionals integrate an understanding of PP and other perinatal mood disorders in classes? 

Jennifer Moyer: I believe education on perinatal mood disorders should be included in every childbirth class.  In fact, when I worked as a Postpartum Support and Education Consultant, I did a presentation on perinatal mood disorders in every childbirth class conducted at a hospital in my area.  By educating the mother and her partner about the risk factors, symptoms and proper treatment, early intervention occurred when a case did occur.  My involvement helped educate the childbirth professionals, which led to them ultimately address perinatal mood disorders on their own in their classes.  To me, the goal is to educate as much as possible so that the information can be passed on to women and their families.  Childbirth professionals have a unique opportunity to reach a tremendous number of women and families as most pregnant women participate in some type of childbirth class.

WK: How would you describe the stigma of perinatal mental health disorders and its impact?

Jennifer Moyer: The stigma of perinatal mental health disorders prevents women from getting help when they need it.  Often because of the stigma and lack of understanding, women are often afraid they will lose their child (children) if they do seek help.  The stigma of perinatal mental health disorders is devastating to families and communities. When families and the community are not educated about perinatal mental health disorders, it makes it difficult for the disorders to be properly addressed, treated and prevented.  I have heard of way too many cases of the mother losing her children because of the lack of understanding and education of perinatal mental health disorders in the community.

WK: What do you see as the most significant barriers to treatment for women with PMADs?

Jennifer Moyer: I believe the most significant barrier is the lack of proper education and training of health care professionals.  Another barrier is the failure of the providers, who are not properly trained, to refer the women to perinatal mental health resources or if no resources available in the area, to consult with an expert in perinatal mental health.  So many women are improperly treated.  I know of many cases where the woman contacted her doctor for assistance and were only prescribed an antidepressant, often over the phone, and received no further direction or support.  So it goes back to education or, in the case of the primary barrier, the lack of education.

WK: Recently, the study The risks of selective serotonin reuptake inhibitor use in infertile women: a review of the impact on fertility, pregnancy, neonatal health and beyond (Domar, Moragianni, Ryley & Urato, 2012) attracted attention regarding the safety of using SSRI medication in pregnancy. Would you like to respond to the study directly?

Jennifer Moyer: I am not a medical professional so I cannot respond in depth but from a lay person’s perspective, this information can cause many pregnant women from seeking help, if they are experiencing any perinatal mental health issues.  My understanding is there is always a risk/benefit analysis when it comes to medication so education about options is so important.  In my opinion, it seems that medication is often the only intervention presented rather than a more complete and balanced plan of treatment, which may include medication when necessary. Educating women about their options should always be a priority but if the health care professionals are not properly educated in perinatal mental health, how can they educate anyone else?

WK: What suggestions do you have regarding how childbirth organizations can encompass perinatal mental health into training curriculum and practice? 

Jennifer Moyer: Offering and requiring specific training on perinatal mental health for all members would increase awareness, education, treatment and most importantly prevention.  Offering continuing education and ways of implementing mental health into their practice would help eliminate stigma and, when necessary, increase referral and treatment to perinatal mental health professionals.

WK: What can we do to increase the understanding that a woman’s mental health is part of maternal health?  

Jennifer Moyer: Although the old saying “if mom is not happy, no one is happy”, puts pressure on moms, it does stress the importance of maternal health.  The health of mothers is critical to society and communities everywhere.  The more mental health is talked about, the better understanding will occur.  As you probably have realized from my previous responses, I am a huge proponent of education.  I believe it is the key to decreasing stigma and bringing about positive changes in the health of women both mentally and in general.

Next Steps

In what ways can childbirth educators participate in bringing about positive changes within this paradigm? How can health care professionals learn more about how the role mother’s mental health plays in so many of the dynamics of the new mother and child(ren). Would you be interested in a webinar on this topic?  Where do you as a birth professional go for more resources, information and teaching tools on the topic of postpartum mental health?

About Jennifer Moyer

Jennifer Moyer has various media experience including her personal story being published in the February 2002 issue of Glamour Magazine resulting in a guest appearance on CNN’s The Point. She was also interviewed for an article appearing in the December 2002 issue of Psychology Today. Jennifer is a member of the National Perinatal Association, the National Alliance on Mental Illness, Mental Health America, The Marcé Society, the National Association of Mothers’ Centers and Postpartum Support International. Jennifer is also now a member of the International Association for Women’s Mental Health.

Please contact Jennifer through her website or by emailing her at jennifer@jennifermoyer.com. Jennifer blogs at: www.jennifermoyer.com/blog

Walker would like to thank Jennifer Moyer, Nancy Byatt, D.O., MBA, and Julia Frank, MD, and the Listserv of the Marce Society for their assistance with this article.

Childbirth Education, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, Newborns, Perinatal Mood Disorders, Postpartum Depression , , , , , , , ,

Perinatal Mental Health and Childbirth Education: Professional Perspectives Part II

December 11th, 2012 by avatar

By, Walker Karraa

Regular contributor Walker Karraa has written an excellent three part series on Perinatal Mood and Anxiety Disorders (PMAD) and what the childbirth educator or birth professional can do to help women get the help they may need when dealing with mental illness during the prenatal and postpartum period.  Walker interviews experts in the field who all offer concrete steps, activities and resources so that educators and others can do to be more prepared to discuss this important subject with students and clients.  Recent press coverage of a British mother suffering from severe PMAD has made headlines and the topic is one that belongs in whatever childbirth class a woman chooses to take.  The first post in the series is here  Part III will appear on Dec 13th, 2012.– Sharon Muza, Community Manager.

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http://flic.kr/p/adyga

We have the opportunity to hear another expert perspective regarding the use of antidepressants, stigma, and the role childbirth education might play in the prevention of perinatal mood and anxiety disorders (PMAD). This installment features Nancy Byatt, D.O., MBA. Dr. Byatt is a perinatal psychiatrist and Assistant Professor of Psychiatry and Obstetrics & Gynecology at University of Massachusetts Medical School/UMass Memorial Medical Center.  Dr. Byatt’s research focuses on understanding and evaluating ways to improve depression outcomes for perinatal women and their children through health care system improvement.  Her current research aims to improve the uptake of evidence-based treatments for perinatal depression in obstetric settings.  I know I speak for Lamaze International in thanking Dr. Byatt for participating.

WK: What can we do to increase the understanding that a woman’s mental health is part of maternal health?  

Dr. Byatt: Providing psychoeducation to women and their partners about the importance of perinatal mental health is a good first step.   Psychoeducation should aim to destigmatize depression and other perinatal mental health concerns and encourage women to engage in treatment.  Providing psychiatric resource and referral source guides may also empower women to seek treatment.  Childbirth educators could also be trained in motivational enhancement interventions that may inspire women to address their mental health concerns.  For example, providing information about health risks, wellness interventions, support groups, psychotherapy, medication options, and other mental health resources can encourage women to engage in treatment.

WK: How might childbirth professionals integrate perinatal mood disorders in classes? 

Dr. Byatt: Childbirth education classes are an excellent opportunity to prepare women and their partner or primary support for the emotional transition to the postpartum period.  Ideally, women should be taught how to take care of themselves both physically and emotionally during this vulnerable time period.  Women and their partners or primary support could be given information about the signs and symptoms of depression so they can recognize depression if it occurs.  It would also be helpful to destigmatize depression and review mental health resources.  Psychoeducation could also be provided about what factors may put women at higher risk for a perinatal mood disorder.

WK: How would you describe the stigma of perinatal mental health disorders and its impact?

Dr. Byatt: Many studies have demonstrated that many women feel very ashamed of perinatal depression and as a result may be less likely to seek help.  More specifically, women may be afraid that they will lose parental or personal rights if they disclose psychiatric symptoms.  They may also fear feeling judged by perinatal health care professionals and/or friends and family.   Acknowledging depression symptoms can also negatively impact women’s view of themselves as a mother.   Unfortunately, these concerns may result is avoidance of mental health discussions.

WK: What do you see as the most significant barriers to treatment for women with PMADs?

Dr. Byatt: Women face many barriers to accessing and seeking help for perinatal depression. Stigma and shame have been consistently reported in numerous studies.  Studies also suggest that interactions with perinatal health care professionals may discourage help-seeking. Some women also report that their emotional needs are not addressed by perinatal health care professionals, perceiving them as unresponsive or unsupportive.  Women also perceive that perinatal health care professionals lack training in regards to perinatal mental health.  Available treatment resources are often limited for both perinatal women and obstetric providers and staff, creating both patient and provider barriers, respectively.

Some typical (but not all inclusive) symptoms of Postpartum Mood and Anxiety Disorders

  • Are you feeling sad or depressed?
  • Do you feel more irritable or angry with those around you?
  • Are you having difficulty bonding with your baby?
  • Do you feel anxious or panicky?
  • Are you having problems with eating or sleeping?
  • Are you having upsetting thoughts that you can’t get out
  • of your mind?
  • Do you feel as if you are “out of control” or “going crazy”?
  • Do you feel like you never should have become a mother?
  • Are you worried that you might hurt your baby or yourself?

Women note numerous factors that impede their ability access mental health treatment, including disconnected pathways to depression care.  Women’s interactions with mental health providers can also be perceived as a barrier to treatment. Women may find it hard to access mental health care due to long wait times or lack of available providers. Women may not know who to call or how to get help or have difficulty finding a mental health provider willing to see perinatal women.  

WK: How would you respond to media-based concerns regarding the safety of SSRI medication in pregnancy? 

Dr.  Byatt: It is imperative to consider risk of untreated depression when considering medication or non-medication treatment during pregnancy.  Multiple studies have demonstrated that perinatal depression can negatively impact mother, infant, child and family.   Maternal depression has been associated with emotional and functional disability in children of depressed mothers.  Although risks have been reported with SSRI use in pregnancy, the preponderance of data is reassuring.

The risks and benefits of treatment with antidepressants should be weighed against the risks of untreated illness.  Does exposure to the antidepressant or untreated illness pose a greater risk?    If treatment with an antidepressant is indicated, then a discussion of the risks and benefits should take place before medication is prescribed.  Pharmacotherapy should be used judiciously and treatment should aim to maximize evidence-based non-medication treatments, such as psychotherapy, in order to maintain or reach remission of the maternal symptoms.

WK: What are your thoughts regarding discontinuation of medication in pregnancy?

Dr. Byatt: Clinical decisions should be based on the risks, benefits and alternatives to medication treatment.  Untreated maternal illness and the potential risks of psychotropic medication must be considered.  It is vital to consider women’s treatment preferences, illness severity, and the risks of no treatment and under-treatment.  Discontinuation of an effective medication often poses more risk than continuation because it carries the risk of relapse and/or in utero exposure to a second antidepressant.

WK: What suggestions do you have regarding how childbirth organizations can encompass perinatal mental health into training curriculum and practice?

Dr. Byatt: A combination of staff training, structured screening programs, and community resource guides may help childbirth education organizations encompass perinatal mental health training into their curriculum and practice.  Training childbirth educators in mental health can allow them to feel more confident discussing perinatal mental health, which in turn may mitigate women’s fears and concerns and activate them to seek treatment.

Conclusion:

I wonder about the perception of lack of training in childbirth education courses as a part of the barrier to treatment noted by Dr. Byatt. Disconnected pathways to care seem a call to action for childbirth professionals. Where women and families find lack of education, empathy, and acceptance –childbirth professionals could provide pathways to better treatment merely through community resource lists.  Training, structured screening programs and community resource guides are good suggestions to not only optimize care for women, but to optimize practices for educators.

If you took inventory of the training and resources you have been given regarding perinatal mental health—what would you find? Do you know what resources are available from your certifying organization for you to use in your classes? Have you read Kathy McGrath’s article on the Lamaze.org website on Baby Blues? What are some of your favorite resources and activities that you use in class to cover these topics? How do you envision your childbirth organization creating or growing pathways in the future to support continued education on this topic?

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About Nancy Byatt, DO, MBA

Nancy Byatt, DO, MBA:  Dr. Byatt’s clinical, educational and research efforts have been led her numerous publications and awards including the Briscoli Award for Resident-Faculty Academic Collaboration and APA/APIRE Junior Investigators Award.   She recently submitted a Career Development Award Proposal to the NIH/NIMH (National Institute of Health/National Institute of Mental Health) in order to develop and evaluate a new low-cost program that aims to improve the delivery of depression care in outpatient obstetric settings.  Her recent publications include:

1. Byatt N, Biebel K, Lundquist R, Moore Simas T, Debourdes-Jackson G, Ziedonis D.  Patient, Provider and System-level Barriers and Facilitators to Addressing Perinatal Depression:  Perspective of Obstetric Providers and Support Staff. Journal of Reproductive and Infant Psychology.  Link to article:  http://dx.doi.org/10.1080/02646838.2012.743000

2. Byatt N, Biebel K, Debourdes-Jackson G, Lundquist R, Moore Simas T, Weinreb L, Ziedonis D.  Community Mental Health Provider Reluctance to Provide Pharmacotherapy May Be a Barrier to Addressing Perinatal Depression: A Preliminary Study. Psychiatric Quarterly, 2012; ePub ahead of print DOI: 10.1007/s11126-012-9236-0.

3.  Byatt N, Moore Simas T, Lundquist R, Johnson J, Ziedonis D. Strategies for Improving Perinatal Depression Treatment in North American Outpatient Obstetric Settings. Journal of Psychosomatic Obstetrics & Gynecology. 2012 Dec;33(4):143-61. doi: http://www.ncbi.nlm.nih.gov/pubmed/23194018

4. Byatt N, Deligiannidis K, Freeman M.  Antidepressant Use in Pregnancy:  A Critical Review Focusing on Controversies and Risks. Acta Psychiatrica Scandinavica. In Press.

 

Babies, Childbirth Education, Depression, Guest Posts, Infant Attachment, Maternal Mental Health, Newborns, Perinatal Mood Disorders, Postpartum Depression , , , , , , , , , , ,