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Better awareness and a new pill could offer relief to mothers suffering from postpartum depression

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(Yadira PEREZ Perez/AFP via Getty Images)
(Yadira PEREZ Perez/AFP via Getty Images)

Editor's Note: If you or someone you know is in crisis, please call, text or chat with the Suicide and Crisis Lifeline at 988, or contact the Crisis Text Line by texting TALK to 741741. You can reach the Postpartum Support International helpline by calling or texting 800-944-4773.

One in seven new mothers experience postpartum depression. It’s a serious condition that can be fatal.

Health professionals are increasingly aware that postpartum depression is serious, and mothers who go through it need understanding and treatment.

A new pill is set to hit the market that could offer real relief to mothers and their families.

Today, On Point: Understanding and treating postpartum depression.

Guests

Catherine Monk, clinical psychologist and Chief of the Division of Women’s Mental Health at Columbia University’s Vagelos College of Physicians and Surgeons. Director of the Center for the Transition to Parenthood. Research scientist at the New York State Psychiatric Institute.

Dr. Leena Mittal, psychiatrist and Chief of the Division of Women's Mental Health at Brigham and Women's Hospital. Program director for the Women's Mental Health Fellowship at the Brigham. Medical Director of Equity and Innovation for the Massachusetts Child Psychiatry Access Program for Moms.

Also Featured

Lisette Lopez-Rose, former postpartum depression sufferer & assistant at Postpartum Support International. (@pmadlatinawarrior)

Transcript

Part I

DEBORAH BECKER: Many people expect that having a child will be one of the happiest moments of their lives. But for hundreds of thousands of people in the U.S. every year, a baby’s birth results in post-partum depression. Lisette Lopez-Rose is now happily raising her almost three-year-old daughter Sybil. But her first months of motherhood were dark.

LOPEZ-ROSE: I found out I was pregnant March of 2020 when the world shut down. It was my first pregnancy ever, my first child, and I quickly felt disregarded post-delivery. Like I was just this empty shell. Every pediatrician and nurse that I interacted with, you know, really cared about the baby and if the baby was thriving.

And I had some feeding challenges, I wanted to breastfeed, and I was not having success with the latch. I wasn't making enough milk and so it just really felt like my competency as a mother was really being measured by whether or not I was able to successfully breastfeed.

BECKER: Lisette found caregivers and family brushed off her concerns.

LOPEZ-ROSE: I was being told by them, like, "It's okay, like you're crying a lot." That was kind of dismissed away as, "Oh, it's the baby blues." Because you're still under two weeks and your hormones are all over the place. And even family, like when I would share like, you know, "I feel incompetent as a mother because I'm not able to provide what I'm biologically made to provide." Right? I'm supposed to, as a mother, as a woman, lactate and I can't even do that, and I can't feed my baby. And yeah, that's kind of how I felt.

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BECKER: After four months, Lisette was back at work. And exhausted.

LOPEZ-ROSE: The symptom that really surprised me was anger and rage. So like I wasn't crying, but now that I had returned to work, I was just like so angry. I was not getting a full night of sleep working and being gone out of the house for like 14 hours. And I just felt such resentment towards my husband and the baby that I was just like the cartoon character, the Incredible Hulk.

I just felt like what I was feeling was Hulk rage, you know, where he is like, "Smash everything." I was ripping things. I maybe would slam a door. I was angry at like the littlest thing, like maybe I found our water jug empty or something and I would lose it. And that just, that wasn't me. Like I've never been like that.

BECKER: A few months later, Lisette knew she needed help.

LOPEZ-ROSE: I started to have some suicidal thoughts, like just, “I am better off not being here, like my husband, my daughter, my family. I'm a burden to them. I shouldn't be here.” (CRYING) And when I thought that, I was like terrified. And I was like, "Oh my gosh, I need to do something. Like I need medication or something. Like, I don't know who to reach out to."

BECKER: As the weeks ticked by, while she was still waiting to see a therapist, Lisette went online and found a support group –and that she says made a big difference.

LOPEZ-ROSE: I just felt like for the first time I was heard like, "Oh my gosh, I'm not the only one. Like this anger and this rage is real. And I'm not the only mom that's going through this." And we all hate the pandemic, and we all are having a hard time bonding with our babies, and we all are resentful towards everyone. And so it was just nice to be able to feel that validation in that moment.

BECKER: Today, Lisette works for that support group, Postpartum Support International. While she is hopeful about the FDA approval for a new pill to treat postpartum depression, Lisette said she also thinks new parents need even more:

LOPEZ-ROSE: I start to think about people like me who suffered in silence and we're not suffering in silence because we need an easy treatment option in a pill form. I really think that we suffer in silence because it’s not just about medication, it's about society reducing the shame and the stigma about mental health disorders as parents. And really increasing mental health services and training people who interact with pregnant or postpartum people and like universal screenings and just asking us the questions and just making it a standard practice. And overall, it's about how we support parents as a society.

BECKER: That was Lisette Lopez-Rose, mother of an almost-three-year-old daughter. She spoke to us from Richmond, California.

I’m Deb Becker in for Meghna Chakrabarti. And this is On Point. This hour, we’re talking about postpartum depression. What it is, why it happens, how it is treated and the hope surrounding a new pill for it.

Joining me first from New York is Catherine Monk. She’s a clinical psychologist and Chief of the Division of Women’s Mental Health at Columbia University’s Vagelos College of Physicians and Surgeons. She's also a research scientist at the New York State Psychiatric Institute.

And director of the Center for the Transition to Parenthood. Catherine, welcome to On Point.

CATHERINE MONK: Thank you. Very glad to be here.

BECKER: So we really want to talk about this new pill and this new way of treating postpartum depression. But first let's explain what it is. We heard Lisette's story, how she felt real darkness, sadness, anger and we've also seen the statistics, perhaps some of us haven't, but the statistics suggest that about a half a million new mothers experience this every year.

So tell us, how do you explain what postpartum depression is and the prevalence of it?

MONK: I think Lisette just did such an amazing job, both in sharing her story and really giving an illustration of all the different factors that can contribute to developing postpartum depression. So we call it a multifactorial condition, meaning many things contributed to it.

First of all, she had a tremendous stressor being pregnant and giving birth during the start of the pandemic. That was obviously a difficult time for everyone, particularly for people who are becoming parents and going through labor and delivery at that time. The sense of isolation.

I often hear from patients that they feel like the candy wrapper, and once the baby is out, the baby's the candy and they're discarded. Aspects of our systems that really could be enhanced to give more of a feeling of support and information and preparing people for it's all night, not bright and sunny, as I think the expectations we have culturally can be. We need to de-stigmatize.

Mental health is part of health. You can't have health without mental health. So it really should be part and parcel, as Lisette was saying, universal screening. Really helping people have supports, reduce the isolation and be on the lookout for the signs early on in getting, there are many different kinds of tools and support groups, tools, psychotherapy and medication when needed, getting that accessible sooner.

BECKER: And what are some of those signs? What are some of the signs people should be looking for?

MONK: Yes. I think, it's, we need to think about, frankly, all mental health conditions, but let's focus on depression and postpartum depression. Is really on a continuum and that there are two sides to that, if you will.

And the one, there's the worry that people, as in Lisette's life can say, "Oh, it's nothing." On the other hand, thinking, wait, these are some warning signs and let's just really be aware. So it's that crying and feeling not oneself, feeling down, feeling self-critical, feeling guilty, that's more than usual and is going on for days and the brightening doesn't happen. Feeling disconnected from one's baby in an ongoing way.

BECKER: Sorry about interrupting.

MONK: Sure.

BECKER: Is it depression or what's the difference?

MONK: Yeah, I really want to stress that there's distress and there's emerging symptoms of depression, and then we go out on the continuum, and we can really diagnose someone with a frank postpartum depression.

But I think we'll all be better served if we reduce stigma and view these early signs as warning signs and getting people into treatment sooner. So again it's on a continuum.

BECKER: I can't imagine, someone going through hormonal changes.

MONK: Yes.

BECKER: Lack of sleep.

MONK: Yes.

BECKER: Adjusting to this whole new life of being a new parent. That's right. And, that's overwhelming in and of itself, so what's some advice about saying, "No, this is a problem." This isn't just adjusting to all of these circumstances.

MONK: It's really the duration and the intensity and how much you're not feeling like yourself and it, and you can't shake out of it.

But I just want to, again, stress that everybody's going to have some of those feelings, and if we help people sooner, when those feelings start to emerge and make mental health care more accessible and support groups, we're more likely to stave off postpartum depressions. And you just highlighted, absolutely, sleep is a huge factor. This role transition.

Also, people's experiences of their own childhoods gets very activated in this time. If there's trauma in the background, that can be a risk factor. Prior depressions can be risk factors. Thinking about the couple relationship and where support is coming from, as you say, there's a lot going on and how much those are challenging issues, the sleep is an issue for everybody, but if you're really susceptible to lack of sleep, that can really, if you will, put people over the edge.

So the more we can be mindful of all these different kinds of issues and look at the warning signs, the more we really can move into a prevention.

I do want to also echo what you just said, that some people are very susceptible to the dramatic hormone changes, and that's another one of our components in this multifactorial understanding.

BECKER: And aside from perhaps a family history of trauma that might be triggered, if you will, by becoming a new parent. Are there other factors that we know of at this point that really increase the prevalence of postpartum depression or make someone a more likely candidate?

So they should be more aware that some of these things that they're going through during this very overwhelming time might be warning signs. So are there other things that people should be considering?

MONK: Yes, absolutely. A past depression and even a past anxiety disorder might get someone to mention this to their obstetrician or midwife that's in their background.

And someone who's really susceptible to mood, experiencing mood changes during their menstrual cycle might mention that. If it's an unwanted pregnancy, that's a significant risk factor. Really lack of support in one's life can be a risk factor. And again, not only a past depression, but going into the delivery period or the pregnancy period in a current depression is a huge risk factor for postpartum depression.

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Part II

BECKER: We're talking about postpartum depression. One in seven women worldwide get it, and the FDA has approved a new pill to treat it. Many of our listeners have reached out on the On Point VoxPop app to share their experiences with this. Here's Amy from Los Angeles and Sandra from Milwaukee.

AMY: Six to eight weeks after giving birth, I just started to notice that I was starting to have very obsessive tendencies and also starting to have very obsessive thoughts. So these thoughts were things that were really far-fetched that would happen to me. If I walked by a window, I would trip, and my baby would fly out. Or just really like out their thoughts that were really gruesome and scary.

Before you have a kid, you hear many people do have postpartum, but it really takes on a new meaning when it shows up in your own life. So, I'm so happy and grateful for this new drug. It just shows that culturally and in society we're giving thought and care to mothers during really the most vulnerable part, I feel, like, of our lives.

SANDRA: When I had my child 42 years ago, it was told to be like all in my head and now it's more recognized as a medical condition, while you're going through the process of delivery and pregnancy. But back in those days, it was considered basically all in the women's head. You were looked upon as being crazy and everything else, and very few people you could talk to about it.

It was like one of those secrets that were kept in the closet.

BECKER: That's On Point listeners Sandra and Amy, sharing their experiences with. postpartum depression. Joining us to talk about this and a new treatment for postpartum depression is Catherine Monk. She's a clinical psychologist and chief of the division of Women's Mental Health at Columbia University, and I want to bring another voice into this conversation, as well.

Dr. Leena Mittal is with me in studio. She's a psychiatrist. And she's also chief of the division of Women's Mental Health at Brigham and Women's Hospital in Boston, program director for the Women's Mental Health Fellowship at the Brigham, and Medical Director of Equity, Substance Use Disorder and Community Partnerships at the Massachusetts Child Psychiatry Access Program for Moms.

Leena, welcome to On Point.

LEENA MITTAL: Thank you for having me.

BECKER: So we've been talking about defining postpartum depression, and we heard from Dr. Monk and we've heard from some of our listeners about their experiences and past experiences in terms of handling some really strong emotions that some new parents experience when they have a new baby.

How would you define it? Would you add to that?

MITTAL: I think that the listeners and Dr. Monk have described it really beautifully, but I think one of the most important things that I notice in our practice is that over time we're really working as a system to try to identify depression and mental health complications throughout the perinatal period earlier.

And I say perinatal period, because we often start to think about mental health in the postpartum period after the baby comes. But the large proportion of mental health conditions and mental health symptoms can emerge even during pregnancy. And sometimes that's not entirely clear to people when they start to experience these symptoms.

BECKER: So if you identify it early, is it easier, do we know enough to say it's easier to treat? Does it treat it differently? Are we talking about something slightly different than what might happen post-delivery?

MITTAL: Some conditions can worsen with time and with treatment not being engaged early.

But the other piece of it is that we think about the emotional symptoms as having an impact on both the pregnancy health, as well as the family system, and that ends up also being unintended consequence of delay in care. And so it's important to really think about engaging treatment as early as possible to decrease suffering, as well as to limit the risks associated with worsening.

BECKER: When we hear numbers and certainly, we got a lot of response from On Point listeners about this, it seems pretty prevalent, half a million new mothers every year. Do you think that's an accurate number or might it even be an under count because of the stigma of this?

MITTAL: I do worry about the undercounting. That one in seven number is really about the general population. But as you start to add on risk factors, as Dr. Monk described, the prior history of any kind of emotional concern, a mood disorder and anxiety disorder, trauma exposure, psychosocial complexity, access to basic needs, all of those rates of emotional complications increase.

And our lives are getting more and more complex, so I imagine that we are underestimating.

BECKER: Catherine Monk who is with us from New York, let's now talk about this new pill that has been approved by the FDA, but it is still under an DFA review period, so it's not as if it's available yet, but a lot of people are excited about it.

What are your thoughts?

MONK: I am also very excited about it. What's exciting about it is that it's a new biological target. It's functioning on the GABAergic systems and it's leveraging neurosteroid hormones, effects on neurocircuitry and mental wellbeing. As opposed to we're been using for years, which are very effective, primarily medications that function on the serotonergic system.

It's also exciting because it seems to have very rapid effects, even within three days. And it's also exciting because as Dr. Mittal alluded to, but just to emphasize, this is really a time when a women's health condition is getting a lot of attention from a pharmaceutical company. And directing the development of a treatment specifically for a condition that primarily women have, which is postpartum depression.

So a lot of excitement for all these reasons. And prior to this, presuming that this will soon be available, more widely available once it goes through this FDA approval process, there was really one treatment and I was astounded to learn that, and I think it was approved in 2019.

So even though we've known about postpartum depression for more than decades, we've had one treatment that's really a very expensive, intravenously delivered treatment. And that's really the main treatment that's been available for women.

MONK: Yeah, I think just a couple of cautionary notes here.

BECKER: Okay.

MONK: One, this is a pill form of that intravenous medication. Also remember that because of the complexity of the brain, basically in the brain, within the body, it is really difficult to develop new psychopharmacological treatments. So I think we need to put it in context.

We also need to remember that the depression in postpartum, while it has some different flavors, as we like to say, particularly tends to have aspects of anxiety that are not always so common in depression across the lifespan. We have a lot of tools to treat postpartum depression and to treat it effectively.

This medication is specifically developed on those with very severe postpartum depression. And the most postpartum depressions, most of the time, are in the mild to moderate range. And we have really great tools for treating postpartum depression. We have different kinds of psychotherapies. We have the existing medications.

We know their risk profile, so we have a lot of tools. Really, in my view, the biggest challenge is helping people to access mental health care and helping with the stigma that's part of our culture still around mental health care.

BECKER: Dr. Mittal, if you could estimate, what would you say, what percentage of patients do you think could be helped by this new pill?

MITTAL: I think it's really important to underscore that the majority of patients that we're seeing are able to be helped by the tools that already exist and that this new medication really offers an opportunity to change the way treatment may be delivered, the pathway for getting better and the timeline with which we can expect relief.

And so, I would, it's hard to estimate exactly the proportion. I think what we saw with Brexanolone, its predecessor, was it was a little bit hard to get a sense of for whom we might prescribe this medication and how do we access it. The oral formulation does make it potentially more accessible, but the proportion of people that would be helped, it's a little bit hard to estimate.

BECKER: As we said, a lot of our listeners wanted to comment on this, and Alyssa from Madison, Wisconsin reached out to us and she said she had coped with depression in the past and she thought she, therefore, wasn't a candidate for postpartum depression. So we can talk about that in a minute, but it did affect her about six weeks after she gave birth and she did eventually find some relief from psychiatric medications, but it took a while. Let's listen.

ALYSSA: I felt like a shell of my former self. This didn't feel like my normal anxiety. It felt darker, heavier. I couldn't eat. I was suffering from daily panic attacks. I couldn't even get out of bed.

I felt guilty that I couldn't breastfeed. I felt guilty that I couldn't take care of my daughter or myself. A few days after Halloween, just before my daughter was 12 weeks old, I hit a breaking point. I began to have suicidal ideation, and I even wrote my daughter a letter because I didn't know if I would make it to the holidays.

And then about seven or eight weeks after I started all those medications, It was like a switch was flipped. I could finally see that light at the end of the tunnel.

BECKER: That's Alyssa from Madison, Wisconsin, who we thank for sharing her story with postpartum depression with us. But she did say that she did find relief from psychiatric medications, but it took some time.

BECKER: So I wonder, Dr. Mittal, if this new pill might help people who are really struggling to get relief faster, could that be a possibility?

MITTAL: That is a really important aspect of this new treatment. The delay in the onset of action for many of the medications that we have can result in people having a pretty significant period of time of suffering. In addition to the access in care delays that we have just in terms of getting connected to someone who might prescribe a medication in the first place, or begin psychotherapy in the first place.

So the rapidity of action is a huge factor in the excitement around this new medication. And also when we think about the impact of emotional complications in the postpartum period, we're really thinking about impact on family interaction, impact on parenting, impact on bonding.

So all of that really has exponential impact afterward. If you were to talk about the things that you most likely would recommend to someone struggling with postpartum depression, if this new pill might only be for those who are really severely affected and maybe a small percentage of patients, what would be the most common treatment, do you think, that people are utilizing at this point?

We heard from a lot of people that really support groups are enormously helpful and feeling heard is enormously helpful. Like what's your typical recommendation to someone?

MITTAL: The mainstays of treatment in our practice are antidepressant medications, psychotherapy, meaning individual psychotherapy, with a trained professional.

And then in addition, peer support. And so peer support can come in the form of support groups. It can come in the form of one-on-one support. It can come in the form of family support. Familial connection and online or in person. So all of those things are really important. And I would say the last piece is self-engagement.

Enhancing people's ability to give themselves permission to do self-care, exercise, nutrition, hydration, sleep hygiene. Those are things I think would be the sort of four pillars of the mainstays of treatment.

BECKER: Catherine Monk, would you agree with that?

MONK: Yeah, I was just gonna say, "Gosh, can I jump in?"

BECKER: Oh, sure. Absolutely. Feel free to jump in. Yeah, absolutely.

MONK: Absolutely. Jump in and so well described. And just to amplify, when we say sleep hygiene, it's a funny term, but we use it all the time. There are a lot of tools we have to help people even in the postpartum period when sleep is so disrupted.

But so that worrying and being activated and getting on ones screens don't then keep you even more awake. So we really have a lot of tools we call sleep hygiene. I just want to emphasize, Alyssa is, in my view, exactly the kind of person for whom this new medication in essence was developed and should be given to.

It's a pretty serious postpartum depression she had, getting to the point of writing her daughter that kind of note, thinking about her own demise. But I also want to emphasize, she's someone where we could see the risk factors. She knew them. She had a history of some anxiety disorders, as Dr. Mittal already said.

I really want to emphasize treating people in the pregnancy period when they're earlier on in the symptom development of that continuum I was describing. If we can start the psychotherapy, start the support group, start the behavioral changes earlier on, possibly her very severe postpartum depression could have been prevented.

BECKER: Yeah. Yeah. Look, and if we just go back to this pill for a moment, we still don't know how much it's going to cost, and we do know that at least the intravenous form of this medication that's being done now is about, I think $34,000. So could this be out of reach for a lot of people? Catherine?

MONK: What I read is that Sage and their collaborators --

BECKER: The pharmaceutical company.

MONK: Yeah. The pharmaceutical, excuse me. The developers are taking this under advisement and saying that they want to work with the insurance companies to make it something the insurance companies will then pay for. I think there are some cautionary notes we need to think about with this medication.

As much as I hope we've both emphasized what is so important, and really something about which to feel optimistic in postpartum depression care, is the concern that it will be overly used, that we have such a problem helping people access mental health care that if this medication, and it should hopefully become affordable to people, it is then in the hands of the obstetricians and other primary care doctors and it really gets prescribed in lieu of other kinds of treatment, other kinds of mental health treatment.

And we're back to what I think was alluded to by even Lisette, is that we are using a pill where we could use a lot of systems changes and policy changes and more support for people. And working on our problem of access to mental health care.

BECKER: And yeah, we know that it's a problem.

Certainly, access to mental health care, but also what about side effects from this particular treatment? What do we know about that and about how breastfeeding might be affected? And both of you feel free to answer this question, but Catherine, let's start with you.

MONK: Yeah, the side effects so far are some dizziness and nausea and having a hard time concentrating.

My understanding is that the breastfeeding profile has not been identified yet in terms of what the impact might be on the child.

MITTAL: Yeah, I would agree with the fact that the side effects, the sedation piece was seen with its predecessor as well as with this medication, the oral formulation in early trials.

I think the most important thing though, to comment on is that I think that the more tools we put in our toolbox, the better for all of us. And so developing medications that can specifically address postpartum depression or perinatal emotional complications get added to an armamentarium or a sort of continuum of treatment.

And so isn't really 'either, or,' but 'both, and,' in my opinion.

BECKER: Do you think that more women are willing to talk about this and there's been an increase of women who are willing to say that they're struggling and seek help?

MONK: Absolutely.

BECKER: Yeah, Dr. Mittal's with me in studio, shaking her head.

MITTAL: Yeah, I absolutely agree. I will say that's maybe a silver lining of the pandemic, is that we've been seeing so much more communication and discourse around mental health needs broadly, not as a society.

Part III

BECKER: We're talking about postpartum depression this hour and new hope about a pill that's expected to hit the market soon, and some other methods that health care professionals are developing to treat postpartum depression.

We've heard from a lot of you, a lot of listeners about this, Catherine from Michigan reached out to us to tell us about her experience, and she said for a full year after the birth of her daughter, she felt alone and stigmatized if she tried to talk about it. So she joined a support group. Let's listen.

CATHERINE: I kept mentioning how uncomfortable I was to friends and if friends of mine had experienced postpartum depression. They weren't talking about it at the time. It was a very painful period. I finally did through my OB, find a support group and hearing other women's stories made all the difference.

BECKER: And we are talking about it this hour.

My guests are Dr. Leena Mittal. She's chief of the division of Women's Mental Health at Brigham and Women's Hospital and program director for the Women's Mental Health Fellowship at the Brigham. Also with us is Catherine Monk, who's a clinical psychologist at Columbia University and a research scientist at the New York State Psychiatric Institute, as well as Director of the Center for the Transition to Parenthood.

And I'm wondering, Catherine, if you might tell us when then you hear stories like we just heard from Catherine from Michigan who called in to talk about feeling very alone in all of this. And right before the break we talked about yes, maybe we're finally paying more attention to women and new mothers who are struggling with this.

What's your advice to folks who may be feeling the way Catherine was feeling, very alone and not able to talk about it?

MITTAL: Yeah, absolutely. To try to talk about it, and I think it was she or others mentioned describing how they're feeling to their obstetrician or their midwife. Hopefully, nowadays, most of those kind of people can make connections either to some mental health support and certainly to Postpartum Support International or other local organizations that can provide support, but first getting into a network where people can be available to you to talk about it.

I think we do, as we go further into this right now, have to talk about how hard it can be to access mental health care, that you can get a referral and it takes weeks to get into the door. And how we might solve that and what are some other approaches, but absolutely. Identifying it and it can be so hard when you're depressed and down.

But really mentioning to people, if we educate each other, so that if you mention it to a sister or a friend, they can get you at least first to Postpartum Support International and trying to get some mental health care.

BECKER: Okay, so let's talk about it. Let's talk about the difficulty of getting mental health care.

Let's talk about what do we do about that? Because we hear about it, not just obviously with postpartum depression, but with all kinds of disorders that are affecting people, especially post pandemic, and we know it's an issue. So what are you hearing from folks and what do you do? That's the question.

MONK: I think we'll be able to describe some different models that are addressing this issue.

There are these access programs and I think Dr. Mittal is working on that in New York, but also, we have, which I oversee in our obstetrical department at Columbia, an embedded mental health program. So the department has directly hired mental health providers and we take insurance and we're really able to see people within a week and if it's emergent situation right away, and of course, deal with hospitalization as needed.

And that speaks to this approach, can address some of the financial challenges of providing mental health care that's insurance based. And part of what's at the root of why that doesn't happen enough, and President Biden is just beginning to address this, is the reimbursement rates for providing mental health care are really not comparable to providing other kinds of care.

And so we don't have parity in the provision of mental health care comparable to physical health care. So having this embedded program does help with some of the financial challenges, in terms of within the obstetrics and gynecology department. It's not just a mental health care service. It provides lots of different services, which can bring in different kinds of reimbursement.

But the bottom line is these embedded programs, mental health programs right in the obstetrical service can really help with the access to care issue.

BECKER: Dr. Mittal, do you have something like that at the Brigham?

MITTAL: Absolutely. We do have embedded mental health care. We do a lot of virtual health care.

Both behavioral health and prenatal care at the Brigham and Women's Hospital. We're also very much focused on trying to think about a no wrong door approach to behavioral health care. So individuals should be able to have behavioral health or mental health needs identified, whether they're at the pediatrician's office for a well-child visit, at their primary care office, at their OB office, during pregnancy or after.

And then also really having the Mass Behavioral Health helpline, for example, and local resources that can lower the barriers to reaching somebody for behavioral health care.

BECKER: I wonder, we've heard a lot and we're very focused on women in all of this, but the whole family is really affected, I'm told.

And we did speak with Lisette at the beginning of the show, and we also talked with her about how it affected her family, her husband in particular, and I'd like to play a little bit of tape of what she said about that.

LOPEZ-ROSE: My husband never had any mental health problems. He's never been anxious, depressed, nothing.

And when I started to get better around eight months when my medication kicked in, I was doing therapy and support groups. He started to go down and I recognized his symptoms. I think he was reflecting, "Oh, that might be me." But not really wanting to admit it. And so when I said that to him, he was like, "You're right, I see it. Yep." And so we had an honest conversation.

BECKER: And so that's Lisette talking about how her husband was affected as well. What do we know about men dealing with some of these difficult emotions after the delivery of a baby? Catherine?

MONK: Yes, we're absolutely learning that men too or the partner in a same sex couple can experience postpartum depression.

And what's really interesting from a neuroscience perspective is that we're seeing, we know actually, and I should back up, that the brain changes dramatically during pregnancy and postpartum, comparable changes to an adolescent's brain. We're used to thinking about adolescents having these phenomenal changes in behavior and personality and feelings.

And of course, it's happening in the brain. And the brain and the pregnant person, pregnancy to postpartum also has phenomenal changes in gray matter density, for example. So what's interesting is we can see also changes in some hormones in fathers, and of course they're not, in a traditional couple, not carrying the baby.

So even the caregiving role activates hormones, and the brain is presumably, we're going to learn more, going through a lot of changes. And in that sense, it's both a time of change and a time of vulnerability. And there can be postpartum depression.

BECKER: And so we want to talk about treatment.

We've got embedded access programs, right? In some areas, that both of you mentioned. We've got this new medication that may be available for some people. We've got some existing psychiatric medications that have been found to be helpful. Are there other areas of treatment that you think might be, might actually offer relief to some folks?

And what about the use of technology? Where are we with that? Because that's used in other mental health areas as well, Dr. Mittal.

MITTAL: I might like to just jump in also to clarify. Access programs and embedded care are a little bit different. Access programs are really ways for non-behavioral health professionals to access immediate real time consultation from a perinatal psychiatric expert. And Massachusetts, for example, has the Massachusetts Child Psychiatry Access program for moms, which is the first of its kind in the nation, to really be a resource, sort of a curbside consultation service and direct consultation service.

And that empowers folks like perinatal care providers, pediatricians, psychiatric providers, primary care providers, to be able to feel more able and to treat behavioral health conditions. And then, in addition, we have embedded care and access to care with direct care, with behavioral health professionals, psychiatrists, and therapists, as well.

BECKER: And then, and just to, oh, I'm sorry. Go ahead Catherine.

MONK: Yeah. Just to add in these access programs, which are really more and more of them are growing up, if you will, around the states. They're particularly oriented and helpful with educating obstetricians and other providers to prescribe medication so they feel they have the knowledge to do, and then they're making links to people in the community for access to behavioral health. And again, that can get us back to our problem of how that resource is really hard to come by and how we need to solve that, systemically.

BECKER: Yeah. Yeah. And what about, are there other things on the horizon for treatment?

Are there other things that you look at, or perhaps some people respond to things that are a little bit unconventional. What about other ways to deal with this?

MONK: I know you mentioned wanting to go into digital therapies, and I know that's going to come up in, in what Leena will describe.

I'll go in quickly into some of what we're doing and really to emphasize, again, we want to start in pregnancy. So there are three programs out there. One which we develop that are evidence-based to prevent postpartum depression. There's the Mothers and Babies program that is out of Northwestern. There's the ROSE program, which is out of Brown.

And then there's our program, PREPP, Practical Resources for Effective Postpartum Parenting. So we take people with some risk factors, each of these programs does and their psychotherapy And use a lot of different tools and have been shown to be effective to prevent postpartum depression and those at risk.

We are starting up postpartum drop-in groups where, just, we even have one of our first ones, someone was in the hospital and joined the Zoom group to get that support. It's run by a mental health provider, a physical health provider, and then a peer support person. So really trying to address issues before they get worse.

BECKER: Dr. Mittal, do you want to talk about, again, some other resources, but also let's talk about technology.

MITTAL: Technology is one of those things that I think has so many different approaches and options that we can really leverage to think about how we're engaging. Individuals are often on their devices so much more often than they are in a provider's office, and so we're able to really utilize that device usage pattern to detect changes in behavior.

But then also utilize those devices intentionally to engage with both screening and detection of symptoms that people are reporting, but also deliver treatments. And so there are a lot of treatments out there that really lend themselves to technological and to digital delivery. Like cognitive behavioral therapy, which is a manualized therapy that can be delivered in a systematized way.

As well as just education, what we call psychoeducation, describing symptoms, describing things to be concerned about, describing pathways to access care. So there's a lot of power within digital technology, but a lot of different ways it can be applied.

BECKER: Is there, are there apps right now that you would recommend to someone?

MITTAL: There are a lot of apps out there. I don't tend to recommend one specifically. I tend to recommend a whole variety of them. A lot of what we to do is think about skills-based interventions and so things that can coach around sleep hygiene as we described earlier. CBT for insomnia, for example, is a great tool.

So we really do have a lot of different tools out there, depending on what people are looking for.

BECKER: With what we're seeing, and you mentioned that you're afraid that it, there could be an under count in terms of the numbers of people who are reporting this disorder. I want to ask Catherine Monk about that as well.

Do you think that while we may not know the extent of this or exact numbers, we are seeing an increasing number of people coming forward who appear to be more willing to at least discuss that this is happening.

MONK: Yeah, absolutely. And maybe, if I'm understanding correctly, part of the question is actually the rates of postpartum depression getting worse, say in the last 10, 20 years.

And/or are more people self-identifying or being identified. And probably both are happening, but it is a confound, if you will. We are so much more aware, and people are talking about it more, that could make it look as if the rates of postpartum depression are getting worse. On the other hand, as you said, I think at the beginning of the show, life has gotten quite complicated.

And faster pace, more demands. This role transition, being a working mother is extremely challenging. Stressors like the pandemic, climate change, other issues that are really of concerns to people, it's possible it is also getting worse. And then frankly, from a neurobiological standpoint, we have things like plastics that disrupt our hormonal functioning. And that is certainly something happening now more than it did 60, 70 years ago.

BECKER: And do you think that's a factor?

MONK: Absolutely could be. These are actively getting researched right now. So we can understand. But these are hormonal disruptors. Some of the chemicals that come from the plastics to which we're all exposed.

BECKER: I want to make sure that we end on a positive note. And we have about two minutes left here and I want some advice that you would give to folks to be able to identify whether what they're experiencing is in fact postpartum depression. And also, what advice do you give to the families of people who are bringing in a new baby and how to best support them? Catherine, you go first.

MONK: How to best support a family bringing home a new baby is to really listen to what they say they need and help them.

That it's going to be changing over time, even over the first day or two. The kind of different support and concrete support they'll need in listening. And I think I really just want to emphasize, any bit of not feeling like oneself is the moment to say, "Maybe there's something not going well enough for me.

And I want to try to get some support and help." Because that gives us the opportunity to give someone tools and support and medication if needed, before we're really in the realm of a frank postpartum depression with the very clear symptoms of hopelessness and guilt and feeling depressed and all the way to suicidal ideation.

BECKER: Okay. We've got just a couple seconds left, Dr. Mittal.

MITTAL: Yeah, absolutely. I think the other piece of this is really to make sure that there are a lot, that people are aware that there are so many different resources out there through a whole variety of providers. Pediatricians, psychiatrists, behavioral health specialists, OB's, primary care providers are all opportunities to really engage in care.

This program aired on August 15, 2023.

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