With the excitement of a new baby, focus often shifts to baby’s needs. Meanwhile, new mothers can experience physical, mental and hormonal changes that can make adjusting to a new life challenging.
Dr. Rachel Shmuts, a psychiatrist at Our Lady of Lourdes Medical Center, discusses postpartum depression, signs to watch for and when to seek help.
Is it Baby Blues or Post Partum Depression?
From the Show: Lourdes Health Talk
Summary:
Air Date: 7/15/18
Duration: 10 Minutes
Transcription:
Melanie Cole: Being a new mom presents its own challenges, but when symptoms of postpartum depression, such as extreme sadness, severe anxiety, and hopelessness get in the way, you need to do something about it, because after all, caring for yourself is as important as caring for your new baby and the rest of your family. My guest today is Dr. Rachel Shmuts. She's a psychiatrist at Our Lady of Lourdes Medical Center. Tell us a little bit about postpartum mood disorders and how common they are.
Rachel Shmuts, DO: Postpartum mood disorders is not just depression. We talk a lot about postpartum depression, but there's a whole slew of disorders that people experience in the postpartum that they say ‘I'm not depressed, but I don’t feel right.’ We actually are starting to call them perinatal mood and anxiety disorders because that encompasses a great range of symptomatology that’s abnormal in the peripartum period. I also say peripartum because now we’re starting to understand that these psychiatric symptoms can start during pregnancy and they're prominent during pregnancy and they are a major risk factor for continuation in the postpartum period. Postpartum depression is definitely the one that we talk about the most because it’s been in popular media and we have a lot of research on it, and you describe very well in the introduction what some of the major symptoms are. Other postpartum or peripartum mood disorders including anxiety can consist of extreme worry, extreme restlessness. I think one of the major symptoms that people experience that they don’t like to talk about, but there's that old adage when about sleeping when a baby sleeps, but people can't because they're too keyed up, racing thoughts, negative thoughts about the baby or themselves, thinking themselves as a bad mother, thinking that something bad or some harm is going to come to the baby. Lots of different things can occur in the peripartum period that are still very stigmatized in that women themselves don’t want to talk about, which is sad because they can be helped and people can get better.
Melanie: Certainly, they can. You mention now that it’s perinatal, really talking about all during the pregnancy, so when is it that you're starting to see some of these? Some of them can happen during pregnancy, right? You worry not only about the pregnancy but then about delivery and worry is natural for us.
Dr. Shmuts: Worry is natural. I'm actually a perinatal psychiatry specialist, so I see patients that come in even before they get pregnant and they're worried about experiencing psychiatric symptoms during their pregnancy and see if they’ve had a history of psychiatric illness, but sometimes a lot of symptoms start during the pregnancy, so I often see people when they're pregnant because they're not sure if what they're experiencing is normal and what's not normal. Like I said before, there's a very large study that looked at the incidences of postpartum depression and other psychiatric symptoms in the postpartum period and we’re under the understanding that 50% of postpartum mood disorders can start during the pregnancy. That’s half. We also know that abnormal anxiety, too much anxiety during the pregnancy, is not normal. It’s an independent risk factor for developing a postpartum depression later on. A lot of women come to me and say ‘is this normal, should I be worrying about this, should I be feeling this way,’ and normal things to worry about when you're pregnant is ‘if the baby is healthy, if it’s a new mom, am I going to be a new mom,’ things that run through your head constantly. Sometimes sleep can be a little bit disrupted, but it’s not greatly disrupted by these worries. Sometimes it could be a little normal to be extra to check on things a little extra often when you're pregnant, so if you want to go for an extra ultrasound just to make sure everything is okay, that’s still normal. When you're worried to the point where they can't sleep, they can't eat because they're so nervous, some people, especially when they're pregnant, if they're so nervous and so worried, they can feel that as symptoms in their body. It can worsen nausea, it can cause nausea, it can cause headaches, it can cause fatigue. It takes a tremendous energy to be worrying all the time, so people who are extreme worriers or very anxious can be very tired also, but then they can't sleep and it’s a vicious cycle.
People who are pregnant who need to hear the baby’s heartbeat five times a day, people who can't relax without any sort of reassurance of definitiveness is worrisome and it can cause dysfunction in that person and some people can't work, they can't focus enough to carry on daily active living. It affects the relationships with their partners and their partners don’t know what to do for them and then they get frustrated and then they get anxious, so these are signs that things are not so good, but a little worry here and there is healthy, because again, it can be motivating for you to do something. For instance, if you're worried about gaining too much weight or having high sugar during your pregnancy and your doctor says you should exercise, then you're worried enough to motivate yourself to exercise and exercise helps you feel better and you're not as worried. That’s a normal cycle. People who are worried or anxious during the pregnancy or postpartum, reassurance helps temporarily but it really doesn't go away. There's no relief from it. It becomes constant. Those are things to be aware of or concerned about if you're pregnant and you're experiencing these things.
Melanie: I really want to get into treatment and treatment options. There's been so much talk in the media, but before we do in just a second, is there a screening for postpartum depression or perinatal mood disorders? Is there some screening that you do with your patients?
Dr. Shmuts: Absolutely. In fact, the US Health Preventive Task Force just came out about a year or two ago that highly recommended and many practices in multiple disciplines are enforcing this. Screening at least once during pregnancy and screening all women of reproductive age for peripartum or postpartum issues. All pregnant women get at least one screening and postpartum at least one screening. We use a variety of different tools. One, of course, is the clinical interview is by far the best. Talking to the patient, asking the questions ‘do you feel sad,' and making it a conversation. It's very difficult sometimes when a doctor asks a patient ‘are you depressed.' Sometimes a patient doesn't know if they're depressed. Some of the times, a woman doesn't know what words to put to their feelings, so using it as a conversation thing, ‘do you feel sad, do you feel you can't laugh as much as you used to,' making it conversive and accessible. We also use screening tools and one of the ones that are most prominently used is called the Edinburgh Postnatal Depression scale. It has utility, validity, and reliability when the person is pregnant. It's a little bit of a misnomer. Nowadays, it's not just for postnatal women. As a reproductive psychiatrist, I do a screening at every contact point and in the postpartum at every contact point. That might be considered excessive for an OB/GYN or pediatrician, but I think it’s important throughout the pregnancy especially if risk factors are pregnant that it should be done at least once a month throughout the pregnancy and with most contact points after the pregnancy. If the women either has symptoms or is at risk for developing symptoms of the postpartum mood disorder.
Melanie: Let's get into treatments and the time that we have left. Women hear about antidepressants, but they're worried about breastfeeding, they're worried about side effects, they're worried about all these things. Just give us a quick rundown on the treatment options and what you tell women about deciding those.
Dr. Shmuts: It’s hard to do a quick rundown, but I’ll try to be concise. There are other options other than medications for when a woman is suffering from a postpartum depression or a mood disorder that's mild to moderate. For instance, the first line of therapy, especially if the woman is breastfeeding, is psychotherapy. There's a variety of different types of psychotherapy. There are group interventions that seem to be successful. There are specialists that are psychotherapists and psychologists and social workers who specialize in peripartum issues, so that is always an option. Sometimes insurance is a barrier because not a lot of private practitioners take insurance, but we happen to be in an area actually where there are a lot of specialists in this area that you can get access to that take insurance. That’s always an option and it can be very effective. Medication, of course, is a major option as well. It doesn't have to be first in line if the symptoms are mild, but if the symptoms are moderate to severe, it can be highly considered. What the stigma is, is that you can't breastfeed on medication. That's actually not necessarily true. There's nothing that's absolutely 100% "safe" in pregnancy barring a perinatal vitamin or folate or breastfeeding, but what we use is a perimeter as to how much medication gets filtered into the breast milk. Usually, we use a cut off of what we call how much is in the mom's blood and how much is in the baby's blood in research studies and case theories. What we find is the cutoff that we arbitrarily sometimes use is 10% or less. 10% of the medication getting into the breast milk. Most medications that we use as the primary or first line of treatment, particularly the SSRIs which we use in the plain old run of the mill depression as well, are under 10%. There are symptoms and signs to look out for in a breastfed baby whose mom is on an antidepressant, but they are very low risk and very rare.
There are other medications that are higher risk, but when we’re talking about depression anxiety, the first line of medications SSRIs tend to be relatively safe and very well tolerated in breastfeeding. They are not mutually exclusive. Women need to know that if you're suffering and you need a medication, just because you're breastfeeding does not mean that you can't be on that medication. It’s all about risk versus benefits and often the benefits outweigh the risks by a lot. There's new and upcoming research that’s very exciting in our field that’s being done by a research group that is looking on a particular compound that is specific for postpartum depression and it targets the sensitivity to the hormonal changes that contribute to the ideology or the cause of postpartum depression, or at least the presumed cause. The preliminary studies are very exciting and very positive and in years to come, maybe in five years from now or 10 years, we may have a first line highly effective treatment that will be specific for these disease complexes. Right now, we don’t have that but we’re in a very exciting time where this compound is not like the other antidepressants we have at all. So far, it looks really good. That might be something coming down the pipe.
Melanie: Wrap it up for us with what you want women to know about seeking help, support and what they can do to better take care of themselves if they do get postpartum depression and speaking to their healthcare provider and really seeking that help because it's so important.
Dr. Shmuts: That’s a great question. I think what women need to know is that not all worry is normal. If it’s starting to affect you and you feel bad and it feels uncomfortable and other people around you are noticing it, it’s probably not normal and that you should get help. You could go to your OB/GYN, you could go to your primary care doctor and discuss these things, hoping that they are well informed. If you have a history of psychiatric illness before being pregnant, you are at risk for developing it during pregnancy and the postpartum and prevention is the best medicine. If you have a history of psychiatric illness and you're on medicine or not, get with a psychiatrist or with some sort of very deep therapy to help prevent any worsening of the disease throughout the major transition of pregnancy and postpartum. There are specialists out there like myself and a therapist social workers group therapy that can help you. With the proper help, with the proper self-care, and I think that's a hugely important issue, without the mom being well cared for, the baby can't be well cared for, the husband or partner can't be well cared for, the family unit can't be well cared of. It's central to the mom in most cases. Take care of yourself first and if that means getting help, there are people available that you can get help. Help is available and with help, you can get better. This is not necessarily a lifelong disease. This is not something you're going to live with forever. With the proper attention, the proper self-care and the proper help, you can get better and lead a happy life.
Melanie: Beautifully put. Thank you so much. You are such a great guest and I can certainly hear your passion about this topic and thank you for sharing your expertise. What an important topic for listeners to hear. You're listening to Lourdes Health Talk. For more information, you can go to lourdesnet.org. That’s lourdesnet.org. This is Melanie Cole. Thanks so much for listening.
Melanie Cole: Being a new mom presents its own challenges, but when symptoms of postpartum depression, such as extreme sadness, severe anxiety, and hopelessness get in the way, you need to do something about it, because after all, caring for yourself is as important as caring for your new baby and the rest of your family. My guest today is Dr. Rachel Shmuts. She's a psychiatrist at Our Lady of Lourdes Medical Center. Tell us a little bit about postpartum mood disorders and how common they are.
Rachel Shmuts, DO: Postpartum mood disorders is not just depression. We talk a lot about postpartum depression, but there's a whole slew of disorders that people experience in the postpartum that they say ‘I'm not depressed, but I don’t feel right.’ We actually are starting to call them perinatal mood and anxiety disorders because that encompasses a great range of symptomatology that’s abnormal in the peripartum period. I also say peripartum because now we’re starting to understand that these psychiatric symptoms can start during pregnancy and they're prominent during pregnancy and they are a major risk factor for continuation in the postpartum period. Postpartum depression is definitely the one that we talk about the most because it’s been in popular media and we have a lot of research on it, and you describe very well in the introduction what some of the major symptoms are. Other postpartum or peripartum mood disorders including anxiety can consist of extreme worry, extreme restlessness. I think one of the major symptoms that people experience that they don’t like to talk about, but there's that old adage when about sleeping when a baby sleeps, but people can't because they're too keyed up, racing thoughts, negative thoughts about the baby or themselves, thinking themselves as a bad mother, thinking that something bad or some harm is going to come to the baby. Lots of different things can occur in the peripartum period that are still very stigmatized in that women themselves don’t want to talk about, which is sad because they can be helped and people can get better.
Melanie: Certainly, they can. You mention now that it’s perinatal, really talking about all during the pregnancy, so when is it that you're starting to see some of these? Some of them can happen during pregnancy, right? You worry not only about the pregnancy but then about delivery and worry is natural for us.
Dr. Shmuts: Worry is natural. I'm actually a perinatal psychiatry specialist, so I see patients that come in even before they get pregnant and they're worried about experiencing psychiatric symptoms during their pregnancy and see if they’ve had a history of psychiatric illness, but sometimes a lot of symptoms start during the pregnancy, so I often see people when they're pregnant because they're not sure if what they're experiencing is normal and what's not normal. Like I said before, there's a very large study that looked at the incidences of postpartum depression and other psychiatric symptoms in the postpartum period and we’re under the understanding that 50% of postpartum mood disorders can start during the pregnancy. That’s half. We also know that abnormal anxiety, too much anxiety during the pregnancy, is not normal. It’s an independent risk factor for developing a postpartum depression later on. A lot of women come to me and say ‘is this normal, should I be worrying about this, should I be feeling this way,’ and normal things to worry about when you're pregnant is ‘if the baby is healthy, if it’s a new mom, am I going to be a new mom,’ things that run through your head constantly. Sometimes sleep can be a little bit disrupted, but it’s not greatly disrupted by these worries. Sometimes it could be a little normal to be extra to check on things a little extra often when you're pregnant, so if you want to go for an extra ultrasound just to make sure everything is okay, that’s still normal. When you're worried to the point where they can't sleep, they can't eat because they're so nervous, some people, especially when they're pregnant, if they're so nervous and so worried, they can feel that as symptoms in their body. It can worsen nausea, it can cause nausea, it can cause headaches, it can cause fatigue. It takes a tremendous energy to be worrying all the time, so people who are extreme worriers or very anxious can be very tired also, but then they can't sleep and it’s a vicious cycle.
People who are pregnant who need to hear the baby’s heartbeat five times a day, people who can't relax without any sort of reassurance of definitiveness is worrisome and it can cause dysfunction in that person and some people can't work, they can't focus enough to carry on daily active living. It affects the relationships with their partners and their partners don’t know what to do for them and then they get frustrated and then they get anxious, so these are signs that things are not so good, but a little worry here and there is healthy, because again, it can be motivating for you to do something. For instance, if you're worried about gaining too much weight or having high sugar during your pregnancy and your doctor says you should exercise, then you're worried enough to motivate yourself to exercise and exercise helps you feel better and you're not as worried. That’s a normal cycle. People who are worried or anxious during the pregnancy or postpartum, reassurance helps temporarily but it really doesn't go away. There's no relief from it. It becomes constant. Those are things to be aware of or concerned about if you're pregnant and you're experiencing these things.
Melanie: I really want to get into treatment and treatment options. There's been so much talk in the media, but before we do in just a second, is there a screening for postpartum depression or perinatal mood disorders? Is there some screening that you do with your patients?
Dr. Shmuts: Absolutely. In fact, the US Health Preventive Task Force just came out about a year or two ago that highly recommended and many practices in multiple disciplines are enforcing this. Screening at least once during pregnancy and screening all women of reproductive age for peripartum or postpartum issues. All pregnant women get at least one screening and postpartum at least one screening. We use a variety of different tools. One, of course, is the clinical interview is by far the best. Talking to the patient, asking the questions ‘do you feel sad,' and making it a conversation. It's very difficult sometimes when a doctor asks a patient ‘are you depressed.' Sometimes a patient doesn't know if they're depressed. Some of the times, a woman doesn't know what words to put to their feelings, so using it as a conversation thing, ‘do you feel sad, do you feel you can't laugh as much as you used to,' making it conversive and accessible. We also use screening tools and one of the ones that are most prominently used is called the Edinburgh Postnatal Depression scale. It has utility, validity, and reliability when the person is pregnant. It's a little bit of a misnomer. Nowadays, it's not just for postnatal women. As a reproductive psychiatrist, I do a screening at every contact point and in the postpartum at every contact point. That might be considered excessive for an OB/GYN or pediatrician, but I think it’s important throughout the pregnancy especially if risk factors are pregnant that it should be done at least once a month throughout the pregnancy and with most contact points after the pregnancy. If the women either has symptoms or is at risk for developing symptoms of the postpartum mood disorder.
Melanie: Let's get into treatments and the time that we have left. Women hear about antidepressants, but they're worried about breastfeeding, they're worried about side effects, they're worried about all these things. Just give us a quick rundown on the treatment options and what you tell women about deciding those.
Dr. Shmuts: It’s hard to do a quick rundown, but I’ll try to be concise. There are other options other than medications for when a woman is suffering from a postpartum depression or a mood disorder that's mild to moderate. For instance, the first line of therapy, especially if the woman is breastfeeding, is psychotherapy. There's a variety of different types of psychotherapy. There are group interventions that seem to be successful. There are specialists that are psychotherapists and psychologists and social workers who specialize in peripartum issues, so that is always an option. Sometimes insurance is a barrier because not a lot of private practitioners take insurance, but we happen to be in an area actually where there are a lot of specialists in this area that you can get access to that take insurance. That’s always an option and it can be very effective. Medication, of course, is a major option as well. It doesn't have to be first in line if the symptoms are mild, but if the symptoms are moderate to severe, it can be highly considered. What the stigma is, is that you can't breastfeed on medication. That's actually not necessarily true. There's nothing that's absolutely 100% "safe" in pregnancy barring a perinatal vitamin or folate or breastfeeding, but what we use is a perimeter as to how much medication gets filtered into the breast milk. Usually, we use a cut off of what we call how much is in the mom's blood and how much is in the baby's blood in research studies and case theories. What we find is the cutoff that we arbitrarily sometimes use is 10% or less. 10% of the medication getting into the breast milk. Most medications that we use as the primary or first line of treatment, particularly the SSRIs which we use in the plain old run of the mill depression as well, are under 10%. There are symptoms and signs to look out for in a breastfed baby whose mom is on an antidepressant, but they are very low risk and very rare.
There are other medications that are higher risk, but when we’re talking about depression anxiety, the first line of medications SSRIs tend to be relatively safe and very well tolerated in breastfeeding. They are not mutually exclusive. Women need to know that if you're suffering and you need a medication, just because you're breastfeeding does not mean that you can't be on that medication. It’s all about risk versus benefits and often the benefits outweigh the risks by a lot. There's new and upcoming research that’s very exciting in our field that’s being done by a research group that is looking on a particular compound that is specific for postpartum depression and it targets the sensitivity to the hormonal changes that contribute to the ideology or the cause of postpartum depression, or at least the presumed cause. The preliminary studies are very exciting and very positive and in years to come, maybe in five years from now or 10 years, we may have a first line highly effective treatment that will be specific for these disease complexes. Right now, we don’t have that but we’re in a very exciting time where this compound is not like the other antidepressants we have at all. So far, it looks really good. That might be something coming down the pipe.
Melanie: Wrap it up for us with what you want women to know about seeking help, support and what they can do to better take care of themselves if they do get postpartum depression and speaking to their healthcare provider and really seeking that help because it's so important.
Dr. Shmuts: That’s a great question. I think what women need to know is that not all worry is normal. If it’s starting to affect you and you feel bad and it feels uncomfortable and other people around you are noticing it, it’s probably not normal and that you should get help. You could go to your OB/GYN, you could go to your primary care doctor and discuss these things, hoping that they are well informed. If you have a history of psychiatric illness before being pregnant, you are at risk for developing it during pregnancy and the postpartum and prevention is the best medicine. If you have a history of psychiatric illness and you're on medicine or not, get with a psychiatrist or with some sort of very deep therapy to help prevent any worsening of the disease throughout the major transition of pregnancy and postpartum. There are specialists out there like myself and a therapist social workers group therapy that can help you. With the proper help, with the proper self-care, and I think that's a hugely important issue, without the mom being well cared for, the baby can't be well cared for, the husband or partner can't be well cared for, the family unit can't be well cared of. It's central to the mom in most cases. Take care of yourself first and if that means getting help, there are people available that you can get help. Help is available and with help, you can get better. This is not necessarily a lifelong disease. This is not something you're going to live with forever. With the proper attention, the proper self-care and the proper help, you can get better and lead a happy life.
Melanie: Beautifully put. Thank you so much. You are such a great guest and I can certainly hear your passion about this topic and thank you for sharing your expertise. What an important topic for listeners to hear. You're listening to Lourdes Health Talk. For more information, you can go to lourdesnet.org. That’s lourdesnet.org. This is Melanie Cole. Thanks so much for listening.
