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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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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 , , , , , , , , , , ,

Serve and Return: Deconstructing the Language of Maternal Mental Health

February 17th, 2011 by avatar

My professional curiosity lies in the power of language to limit, or liberate the lived experience of the childbearing woman—particularly those with perinatal mental health concerns.

Maternal Depression Can Undermine the Development of Young Children (2009) illustrates the positive strides being made to increase awareness of perinatal and postpartum mental health. This Harvard University working paper was a joint effort of the National Forum on Early Childhood Program Evaluation, and the National Scientific Council on the Developing Child, and published by the Center on the Developing Child at Harvard University.  As a psychologist, Ph.D. student in Transpersonal Psychology, birth doula, and mother managing the disease of major depression, I fully recognize that my personal experience influences my professional view.

Maternal Depression Can Undermine the Development of Young Children offers insights as to how childhood development experts view and describe maternal depression.  Increasing awareness of PPMAD (perinatal, postpartum mood/anxiety disorders) in all aspects of family care is crucial to making changes to prevent and treat it. However, the terminology used in the paper, and omission of the full spectrum of PPMAD demonstrate how casual use of language perpetuates stigma and stereotypes regarding maternal mental health.


Titles Are Important

The title, Maternal Depression Can Undermine the Development of Young Children reads, to me, as something I would hear on cable news, rather than a professional paper. Moreover, the term “maternal depression” is the primary descriptor used throughout the paper, rather than the more accurate “perinatal”, or even the somewhat outdated “postpartum” maternal depression.  Not using a puerperal adjective removes context of recent birth.  There is a difference.

“Because chronic and severe maternal depression has potentially far-reaching harmful effects on families and children, its widespread occurrence can undermine the future prosperity and well-being of society as a whole.” (p. 1)

Wow. Not only do depressed mothers hurt children; apparently we also have power to take down all of civilization!  I picture myself the ultimate evil villainess, “depressed mom” in my lair. In my never ending desire to undermine the future prosperity and well-being of society as a whole, I send out my far-reaching harmful effects to terrorize civilization in search for Zoloft. Children and family be damned! I have society to ruin.

The mental health of our mothers is a crucial component to healthy families and communities. But unless we unpack this kind of language, we perpetuate an unconscious belief that “mentally ill” mothers are dangerous mothers.


What is Maternal Depression?

“Characterized by a low mood and loss of interest in usually enjoyable activities, depressive symptoms include difficulty sleeping and concentrating, loss of appetite, feelings of worthlessness or guilt, and low energy. In the face of major clinical depression, the drive, energy and enjoyment needed to build and maintain positive family relationships recedes.”

Set within the prose of the article opinion, leaves symptoms in the realm of the murky. I hate to say it but for much of science, if it isn’t codified, it doesn’t exist.  If the reading audience is not medical professionals, all the more reason to be extremely clear with how medicine describes the disorder. Omitting the full DSM-IV-TR, or ICD 10 diagnostic criteria is a subtle invalidation.  It remains a “mood”/emotional/mental disorder. Furthermore, it is not an accurate representation of the actual diagnostic criteria.  There is no indication of time of onset, duration of symptoms, co-morbidities, symptoms of anxiety with depression, differential diagnosis, or how many symptoms need to present simultaneously to fit criteria.  (Go here for complete list of criteria.)

Prevalence and Effects
According to the authors, in the section subtitled: What Neuroscience and Developmental Research Tells Us, the majority of research on this subject is on maternal postpartum depression.  This is Harvard University. The power of that should not be diminished. When a group holding academic status defines something, we believe it, we repeat it to others.  Not having included all perinatal and postpartum mood/anxiety disorders (PPMAD) in the literature review missed the opportunity to recognize the research that has been done in PTSD after childbirth, and perinatal anxiety disorders.

Furthermore:

“About one in eleven infants will experience their mothers’ major depression in their first year of life”.

This wording suggests mothers doing something to the infant. It personalizes a medical condition. That the relation to the object for our attachment theory readers, WILL be negative. I doubt a public health paper would say, “About one in eleven infants will (powerful word) experience their mother’s diabetes in their first year of life”.

“When raised by a chronically depressed mother, children perform lower, on average, on cognitive, emotional, and behavioral assessments than children of non-depressed caregivers….such patterns forecast difficulties later in adult life across a variety of important domains”.

Some readers may find this language suggests that depressed mothers are bad mothers, and cannot take care of children. This is myth.  Depressed women are not inherently incapable women.  Depressed mothers are not inherently incapable mothers; they are suffering a medical condition that challenges some of their current capabilities but is also completely amenable to proper treatment. I would encourage readers to read my interview with Katherine Stone at www.givingbirthwithconfidence.org for an example of resiliency.

Ping Pong and Problematic Parenting
The Paper authors acknowledge the evidence-based, substantive data demonstrating a correlation between “maternal depression” and fetal, neonatal, and early childhood development.  They are spot on to bring this data to the forefront of child development. However, word choice is extremely important when approaching an issue that has a history of stereotyping, particularly when describing it to professionals who may not be familiar with the issue. The data cited in the Harvard paper:

  • Chronic depression can manifest itself in two types of problematic parenting patterns that disrupt the “serve and return” interaction essential for healthy brain development: hostile or intrusive, and disengaged or withdrawn.
  • Children who experience maternal depression early in life may experience lasting effects on their brain architecture and persistent disruptions of their stress response systems.
  • Maternal depression may begin to affect brain development in the fetus before birth.
  • Depression often occurs in the context of other family adversities, which makes it challenging to treat successfully.

And, while not in bold-face, authors use the serve and return metaphor throughout the paper:

“When caregivers are sensitive and responsive to young child’s signals, they provide an environment rich in serve and return experiences, like a good game of tennis, or Ping-Pong.”

Sports analogies for the intimate interaction between mother and child are at best not creative, at worst insulting.  Perhaps one of the flaws of working papers is the assumption that readers can’t intellectually handle the material, and in an attempt to be understood, unfortunate metaphors are employed.


Suggestions and “Other Serious Adversities”

Hidden in all of the rhetoric, however, is good data. Shuffled off  in footnotes, there are wonderful studies referenced that offer serious contributions to what we are learning about the effects of untreated maternal mood and anxiety disorders. It is a shame in a way, as the second half of the paper offers learning opportunities around looking at program evaluation, policy, and implications for the future. But one has to weed through this kind of language to find the fruits of knowledge. A few more examples for our discussion:

Authors examine outcomes of current programs addressing “maternal depression” and conclude important issues regarding prevention and early intervention. Prevention is key. Early intervention is incredibly important. Treatment is essential and challenging. Here is their interpretation:

Prevention:Given the potential negative consequences of depression for both mothers and their children, a variety of interventions have been designed to prevent and treat it as well as to buffer children from its harmful effects.”

What is your reaction to this finding, and then to the wording?

Early intervention: “ It is not commonly understood that even young children are likely to be affected by their mother’s depression and these effects may be lasting. Moreover, ongoing depression after childbirth is linked to patterns of parenting that may disrupt the normal “serve and return” interactions between an infant and mother, thus potentially harming the child’s developing brain architecture and emerging skills.  By intervening early, before these effects can accrue, we increase the likelihood that children of depressed mothers will grow into healthy, capable, fully contributing members of society.”

Reflect on your reactions to this wording.

Treatment: “Intensive intervention efforts that focus specifically on mother-child interactions have shown promising results in several recent studies.

Wonderful information has emerged in studies showing improved cognitive behavior when mother-infant interaction is coached in brief sessions, over the first year of baby’s life.  Some of the best information the paper offers, and leaves wonderful questions about the efficacy of our current intervention paradigms.

“Research indicates that various combinations of psychotherapy and educational treatments focused exclusively on adults can be effective in reducing depressive symptoms in mothers but appear to have limited impacts on the development of their children. These findings have led several researchers to argue that therapies should not only treat the mother but should also focus on the mother-child relationship.”

I hold a deep belief in the potential of communities of women to facilitate tremendous growth through inclusive, expansive, and multiple levels of consideration and consciousness. Five studies are cited here, the most citations for any one single conclusion in the paper. Interestingly, the citations come from research in the disciplines of psychiatric, psychology, and infant mental health, in contrast to the traditional medical fields supporting first half of the paper (epidemiology, orthopsychiatry, neurobiology, biology, and immunology). The language is less of the uni-directional, mother-based disorder speak.  Traditional treatment paradigms are challenged. Here is where we can all become inclusive and expand professional and societal understanding of perinatal mood disorders. Cleaner language lends itself to learning.

Now, back to the crazy mommy bat cave to complete my mission to undermine civilization with mood swings, crying jags, coma-like responses to my children, and bad tennis.


Posted By: Walker Karraa, MFA, MA, CD

Patient Advocacy, Perinatal Mood Disorders, Research, Science & Sensibility, Uncategorized , , , , , , , , , ,