Unveiling Postpartum Depression: Essential knowledge for Counselors

I'd like to welcome everybody to today's presentation on postpartum depression. I'm your host, Dr. Donnelly Snipes. We're going to define postpartum depression and identify the signs of postpartum psychosis. We'll explore risk factors, screening tools and protocols for postpartum depression. And then we'll discuss the impact of postpartum depression on the mother, child and family. And family finish by exploring current biopsychosocial interventions for postpartum depression. Postpartum depression usually occurs in the first four to six weeks after giving birth and is unlikely to get better by itself. Now, there are some triggers during that period that can contribute to the development of postpartum depression. However, the cognitions, the guilt, the frustration, the things that occur as a result of the initial postpartum depression often linger on and is one of the reasons that we see that postpartum depression is unlikely to get better by itself. 50% of patients experience depression for more than a year after childbirth. Just kind of let that sink in. Women who were not receiving clinical treatment, 30% were still depressed up to three years after giving birth. So that tells us that something is going on here that is a little bit different. That tells us that there may be some environmental factors that are contributing. We're not sure, unfortunately, we're still not sure because there are so many potential confounding factors. But we're getting better. Perinatal mood disorders are those disorders that occur between 20 weeks of gestation to 4 weeks of age of the infant. But we don't want to rule out, we don't want to not call it postpartum depression if it happens more than four weeks later, you know that it does happen. We saw in this slide, slide up here that it could occur in the first four to six weeks after giving birth. So there's kind of a wide range. And I've seen people who do okay, you know, they may have some level of postpartum depression. But I've seen if they are breastfeeding and then when they eventually stop breastfeeding, the alterations in gonadal hormones that occur at that point point can also trigger postpartum depression or a worsening of postpartum depression. According to the CDC, up to 20% of new mothers experience symptoms of postpartum depression. This is more than just baby blues. Postpartum blues or baby blues is relatively common disturbance in people with new babies at home with crying, confusion, mood, liability anxiety, and depressed mood. The symptoms usually appear during the first week postpartum, last for A few hours to a few days and have very few negative consequences. Okay, so this is a, an episode, if you want to think about it that way. Postpartum depression doesn't just remit after a few days, and we don't want to minimize it. If somebody is having symptoms when they present, we don't want to say, oh, that's probably postpartum, but baby blues, you know, you'll be fine. We, we don't want to invalidate, we don't want to minimize what's going on at the other end of the spectrum. So you have baby blues in the middle, you've got postpartum depression. The other end of the spectrum, we have postpartum psychosis, which refers to a severe disorder beginning within four weeks postpartum with delusions, hallucinations, and gross impairment in functioning. Postpartum psychosis is significant. Postpartum depression begins in or extends into the postpartum period, and core features include dysphoric mood, fatigue, loss of appetite, sleep disturbances, anxiety, excessive guilt, and suicidal thoughts. For at least one month. Okay, we don't want people to be going for at least one month before they finally seek treatment, because during that month, they are struggling, they are feeling awful, they're feeling awful about themselves a lot of times. And it's also often damaging to that, to the bonding and attachment between caregiver and child. Postpartum psychosis is a rare illness. Compared to the rates of postpartum depression or anxiety. It occurs in approximately one to two out of every thousand deliveries, or approximately 0.1 to 0.2% of births. The onset is usually very sudden and most often, but not always most often within the first two weeks postpartum. The most significant risk factor for postpartum psychosis is a personal or family history of bipolar disorder. You would have thought a family history of schizophrenia, but no, a personal or family history of bipolar disorder or a previous psychotic episode. So if the person had schizophrenia or some other disorder that had psychotic features to it, including major depression with psychosis, then they are at a greater risk. Mood stabler mood stabilizers like valproic acid have a high rate of causing multiple congenital abnormalities, as do other mood stabilizers. So many women, when they give birth, if they have bipolar disorder, are unmedicated, which means not only do they have the normal hormone fluctuations and mood lility that a lot of people have, but it also means that they have the confound of having bipolar disorder. Symptoms of postpartum psychosis, delusion or strange beliefs which are ego syntonic, they Believe that whatever they're seeing is adequate or is accurate. And even though other people say no, your child does not have germs, you know, like penetrating their skin or whatever their delusion is, the person with postpartum psychosis believes it to be true. Just like any other psychotic episode, they're egosyntonic. If somebody with schizophrenia tells you that the sky is purple, arguing with them, telling them that they're mistaken isn't going to get you anywhere. Because it's ego syntonic. It's their reality. They may have hallucinations. They may feel very irritated, demonstrate hyperactivity, have a decreased need for or inability to sleep, paranoia or suspiciousness, rapid mood swings or difficulty communicating at times. And I keep saying, or because you need a couple of these different criteria in here. But we want to emphasize that if any of these are showing up, it's worth having the person screened. Now, why did I go through postpartum psychosis so much in this presentation on postpartum depression? Because a lot of people think one, that they're the same thing, and they're not. There are a lot of people who have postpartum depression. There are very a lot fewer people who have postpartum psychosis. Now, postpartum depression can get worse and progress to postpartum psychosis. That's not unheard of. But postpartum depression, even with scary thoughts, or especially with scary thoughts, is still postpartum depression. Scary thoughts are one of the things that troubles me most when people work with people with postpartum depression because we have stigmatized a lot of symptoms that go along with postpartum depression, and scary thoughts is one of them. Scary thoughts are a very common symptom of postpartum depression. It does not mean that the person has postpartum psychosis. Scary thoughts thoughts are ego dystonic. The person is saying, I'm having these thoughts and this is not normal. I'm having these thoughts and I really don't want to do this, but I see horrible things. The fact that their ego dystonic is good. The fact that the person is bothered by them is good because that differentiates or helps to differentiate between postpartum psychosis. Scary thoughts can come in the form of words. What if I. What if I put the baby in a bath that's too hot? What if I forget the baby in the car seat and lock them in a hot car? What if I, you know, all of these things that could possibly go wrong? We also may have people with scary thoughts that have images imagining the baby Falling off the changing table, or when they close their eyes, they see themselves doing horrible things to the baby. And they will say words like that, horrible things. Or I see myself, you know, stabbing the baby or doing something horrible. And it terrifies me. I am afraid to be alone with my child. The first part of that or my reaction to that usually is the fact that you are afraid to be with your child shows me how much you love your child. The fact that these thoughts are scary to you, that that's a very normal reaction. And then I start educating them. And if you go to this website that I have linked for scary thoughts, it's all about how common scary thoughts are in people with postpartum depression. And some people with postpartum depression, this is like one of their main symptoms. And, but we don't talk about it, we don't ask about it. And a lot of times women won't volunteer it because they're afraid if they say something like that that they will be hospitalized and, or their child will be taken away. So we do need to advocate and destigmatize these thoughts so women can start talking about it and getting support. Scary thoughts are not an indication of psychosis because they are scary. Because the person says, this is, this is not okay. That's a great sign. Scary thoughts can also be part of postpartum obsessive compulsive disorder, which impacts between 3 and 9% of people with postpartum disorders. Now, they can have postpartum Depression and Postpartum OCD or just Postpartum OCD or just PostPartum depression. But it is important to recognize, and this was something that I didn't know until I started studying up on it, that some people develop obsessive compulsive disorder in the postpartum period. In this situation, the symptom presentation appears as, quote, a predominance of obsessional thoughts concerning harm to the infant as opposed to the traditional obsessions and compulsions like contamination, hoarding, counting, etc, so someone with postpartum OCD is constantly having these obsessional scary thoughts. It's like every time they sit down, every time they are, are trying to do anything, whenever they're alone with the child, they start having terrifying thoughts that they are going to do something wrong, that they're going to hurt the child. Sometimes this can result in habitual behaviors, compulsions to try to, you know, allay it. If there's a period where they don't have these symptoms, they may say, oh well, if I do xyz, then Maybe I won't have these thoughts or these feelings. So you can see how superstitious reinforcement can create some OCD characteristics in someone who's having these floods of obsessional thoughts. Scary thoughts will often make the person feel like they are a bad caregiver. And, and generally we don't see scary thoughts in the non birth parent caregiver, whatever we're labeling them as, because there aren't the wide swings of gonadal hormones that we see in the, the person who actually gave birth. But we do want to recognize and educate the entire family. You know, the, the nuclear dyad, or, you know, if we have extended family, the people that are the adults in the family, that this could happen. And it doesn't mean that the person's a bad parent. A lot of times the thoughts themselves make the parent feel guilty and ashamed that they even have these thoughts about doing something to their child. And they question, why am I having these thoughts? You know, I'm so grateful to have this little bundle of joy. And instead of being this beautiful moment, I'm terrified all the time. So they are confused about why that might be happening. And people surrounding them, especially if they're not talking about the scary thoughts, may not understand why they're distancing themselves from the child. But in their mind, that might be the only way to keep the child safe because they're afraid of being around the child. So we do want to normalize, or at least, well, normalize, destigmatize these thoughts. Yes, the person does definitely needs help dealing with these thoughts, but also the guilt and the shame around it. We need to help family members understand, or other people that are in the support system understand how they can support the person who's having the scary thoughts. And I'll share with you. I went through a doozy of postpartum depression with my son. And one of the things that my husband would do, you know, he had to work, but if I would start having an episode, you know, I was able to call him and a lot of times we would just be on the phone and he was at a desk job at that point in time, and he was able to continue working. He didn't have to talk to me the whole time, but I needed that lifeline, I needed that connection so that I felt like I was safer. I felt like I was less likely to do some of the horrible things I was seeing in my head. So it's important to help families navigate how this happens and educate them again about how common it is. And it has no bearing on the person's capacity to be a parent. We need to remind them that the thoughts are not about who they are, Because a lot of these are ego dystonic as far as what they would even do anyway to anything, let alone their own child. Scary thoughts typically focus on the baby, but can also center on thoughts about the person or their partner. Scary thoughts can be intermittent or constant, and they may be accompanied by those compulsive behaviors like checking on the child to make sure that they're still okay, or if they're having fears of using a weapon to hurt the child, Making sure that the weapon is locked up. Or, you know, there are a lot of different checking behaviors. Some examples of scary thoughts. I'm afraid I might take one of the knives in my kitchen and stab the baby. I can picture myself driving off the road with my baby in the car. I think my family would be better off without me. I'm having sexual thoughts about my baby. Or I can see terrible, graphic, violent things happening to my baby. Now, if a mother says this, we don't want to dismiss it and go, oh, those are just scary thoughts. You'll be fine. You know, we want to say, okay, when you have that thought, what can you do to help yourself feel safe? We want to educate her about where it might be coming from. But it's also again, important to say, okay, you know, if you have this fear, what can you do to help yourself feel safe and let yourself know that the baby is safe? It could be taking the baby and going to a neighbors or taking the baby and going on a walk so they don't. So they're out in public somewhere. Could be calling a friend and being on the phone. There are a variety of different things that they can do, but we don't want to leave them just sitting with these thoughts going, okay, when are they going to go away? Possible interventions help them distract themselves. Use distress tolerance skills. And that's easier said than done. But encouraging them to make a list of things that they can do, Such as putting the baby in the stroller and going on a walk, can be very, very helpful. Encourage them to practice radical acceptance. Okay, crap, I'm having one of these feelings again Or I'm having one of these thoughts again and I have a list of things that I can do when I feel this way. Practice mindfulness exercises, Helping them get regrounded to where they are. You know, five things that they see, four things that they hear, three things that they smell can help them distract their attention so Their mind is not just playing that same statement or that same image over and over again. Remind yourself that you won't always feel this way. Some obgyn pediatricians may recommend medication for women who are really struggling with postpartum depression and or scary thoughts. And that's okay. And it's important to also destigmatize taking medication if it's needed because the scary thoughts and the postpartum depression can wreak such havoc on the attachment and the child's early years, you know, infancy development. That is really important to do everything we can to help the primary caregiver be as attentive and present as possible. Encourage the woman to tell someone she trusts how she's feeling and let them reassure her that she will be okay when she gets the treatment that she needs and that she's loved and safe. And not just saying you'll be okay, but saying there are treatments and you can get help for this and you know, I'm here to support you. That's what we really want. If she feels that her thoughts are out of control or she cannot manage the intrusion, then make a referral to the parent, a perinatal specialist psychiatrist, or call 911 if they are feeling especially agitated. There may be a time when where they need to go be evaluated in an emergency room. As I said, postpartum depression can progress to postpartum psychosis, but the scary thoughts are always a good sign that it's remaining ego dystonic. However, a woman who is having difficulty managing them can become suicidal because she's so afraid she's going to hurt her infant that she may feel the infant is safer if she is no longer around. So we do want to recognize that there is an increased increased risk of suicide if she feels completely out of control. If the woman's thoughts are worrisome to you, but she feels her thoughts make sense and everybody else may be crazy, remember, that's an indication of psychosis is an emergency and needs to be evaluated immediately by a psychiatrist or a physician. Women who've experienced postpartum depression have a 50 to 62% risk for future depressions. Now, a lot of these things I'm going to say women, but again, recognizing that men also can get postpartum depression because their testosterone levels change when a infant is brought into the home and that impacts the neurotransmitters. But most of the. Well, all of the studies have really been done on women with postpartum depression, particularly the birth woman. So we do want to recognize that there Is a better than average chance that this. If this is true for women, then it's also probably true for their partner. Other risk factors for postpartum depression include a history of mood disorders or premenstrual dysphoric disorder, alterations in sex, stress or thyroid hormones. And we'll talk about that more in a minute. Depressive symptoms during pregnancy, a family history of psychiatric disorders, significant negative life events, a poor or strained marital relationship, having a special needs or medically fragile infant. And one of the confounds you might see in with postpartum depression because they speculate it's a confluence of things. Changes in hormones, lack of adequate quality sleep. You know, a bunch of things go together. If you have a woman who gives birth to a child that ends up in the NICU for an extended period of time, then you may see a delay in or a gradual increase in symptoms of postpartum depression that starts to become much more significant when the baby comes home from the hospital. There is a lot of stress associated with having a medically fragile infant. If the person had substance use disorder, an eating disorder or other history of family dysfunction, it also can be a problem in terms of postpartum depression in partners. Some of the risk factors that are more prominent include changing roles and responsibilities. All of a sudden becoming a new parent. You know, they weren't carrying this little bundle of joy around in their body for 10 months. So it may feel a little bit different to them. It may feel more real. All of a sudden they may feel excluded when all of the attention is on the new baby. Babies need a lot of attention, even ones that are not high needs, but high needs babies can also demand even more attention. And the partner or the other family members that are helping out may feel like they are simply there to be full time nannies. And you know, because everybody is handing off the baby and there's no time for them, which can contribute to feelings of distress. There can be missing of the sexual relationship early. You know, generally if you have a traditional childbirth, it's like six weeks before you're supposed to have sex again. But you know, there are other ways of being intimate. However, when you're exhausted, when you're breastfeeding, when you're up every three hours, you may not have the, the person, the mother may not have the energy to or even be thinking about that because, you know, hormone changes, you know, libido is typically lower when a new baby is in the house because biologically the, your energy is supposed to be devoted to, to ensuring survival of this little thing and not necessarily creating a new one already. And the partner may feel overwhelmed at the financial and care obligations. Other children may also feel abandoned, jealous or resentful of the new baby, which can add additional stress and or guilt to parents. Just bringing home a new baby requires a lot of the caregivers. Both caregivers attention and other children may have negative reactions to that. The children that are in the house, especially if they're older, may have changes in duties. They may be expected to do more, which they may may resent. So we do want to recognize that bringing home a new baby or having a new baby can and will alter the system dynamics. Even if that baby is still in the nicu, if that baby stays in the hospital, parents are often worried about the baby when they're home and going into the hospital a lot to see the baby, which again means that it's a change in the functioning of the system. Impact of PPD in the prenatal period A person who has postpartum depression may experience inadequate prenatal care. They may just not bother going to the doctor, or they don't have the energy to worry about it. Uh, they may be depressed that they're even pregnant. Um, you, some people are not happy about it and that can impact their willingness to take care of themselves. They may have poor nutrition. You know, when you're not feeling it or you're too depressed to handle it, or sometimes because your morning sickness is so bad you're having difficulty eating. That can also contribute to mood changes and the development of postpartum depression. This can result in a higher rate of preterm birth, low birth weight, preeclampsia and, and spontaneous abortion. So postpartum depression in the prenatal period is still a big deal. Unfortunately, there are not a lot of medications that are safe for, especially psychotropics, safe for women to take when they are pregnant, especially in the first trimester, usually not even in the second trimester, third trimester. Some medications, the benefits outweigh the risks, but that's a decision between the woman and her obstetrician during infancy, a woman with postpartum depression, or I'm sorry, parents with postpartum depression, because this actually applies to both caregivers if there is a lack of, or an inability for the caregivers to be emotionally attentive, physically connected with that child. What does this sound like? This sounds like your very first adverse childhood experience. You've got a caregiver in the household with a mental health issue. So they are Having difficulty attending to the baby in a responsive fashion. This results for the infant in anger and distancing and averting their gaze. They hypothesize this is protective coping. Some infants may become passive and withdrawn. They just, they kind of don't fuss about anything. A lot of times there's poor self regulatory behavior. The child may not be able to self soothe and dysregulated attention and arousal responsiveness. Sometimes they may be aroused, other times they may not. They may have an exaggerated startle response. But you see some challenging behaviors developing. And all of these, if you look at them and think about, you know, what's the function of these behaviors? Because the infant's not sitting there thinking, hmm, what can I do to really screw with mom and dad? These are all survival mechanisms. From an infant that feels unsafe. Anger can be a way, you know, you are too overwhelming to me. You're, you feel threatening to me. Passivity. If I just sit here and don't make a sound, maybe they won't hurt me or whatever. Poor self regulation and dysregulated attention. I'm out of control and there's nobody to help me get it under control. So I feel unsafe, which makes me feel even more out of control. So it makes sense. Cognitively, the infant eventually develops lower cognitive performance. Socially, caregivers with postpartum depression exhibit fewer instances of and the studies looked at moms and and their children maternal child touch and positive engagement activities such as reading books, singing songs and playing games. You can extrapolate that this would be similar if the if a male has postpartum depression. Caregivers with PPD also display less sensitive behaviors toward their children, tend to respond to their children's needs and a less responsive, attentive and nurturing manner. This is not malicious. Caregivers with PPD are just, you know, doing the best they can to try to survive and responding to the almost constant needs, it seems sometimes of infants can be exhausting. And the caregivers may just really be struggling and they're doing the best they can. But their best is less responsive, attentive and nurturing than people without ppd. These withdrawn behaviors inhibit the formation of a caring and attentive primary attachment. That's important because we know that lack of the development of a secure primary attachment leads to a whole host of other problems. The attachment relationship also suffers from a lack of physical touch, which is crucial to the development of children's regulatory skills and the ability to cope with stress, especially especially in infants. They don't understand Language they don't understand soothing words. They can understand soothing voices a little bit if you talk to them in a calmer manner. But touch increases the release of oxytocin, which can help with calming some. And especially like with kangaroo care, if the child's being held, they can feel the caregivers respiration. They sometimes can hear the caregiver's heart and a lot of times they will sync up. You know, if you've ever slept next to, you know, really close to somebody and notice that, you know, sometimes you end up syncing up your breathing with them. The same thing is true for children. So children, especially infants, don't understand. Okay, let's take a few deep breaths. You know that's not going to go over but if you're holding the child and you start breathing slower, more slowly, then they're going to start breathing more slowly. They don't do it like right away. It's not like they're like oh, this is what we're doing. But you will see that as the, if a caregiver is holding a child, especially if the more agitated the caregiver gets, the more agitated the child gets, the calmer the caregiver gets, the calmer the ch. The the child gets. They take their cues from the respiration, from the, the heart rate and, and from the pheromones that are being secreted from the caregiver. Toddlers who had a parent with postpartum depression, even if the postpartum depression is pretty much resolved right now, they may, toddlers may be more passively non compliant. They just ignore you. They may have a less mature expression of autonomy. They either demand to get their own way all the time or they don't try to. They don't try to do anything. They're not trying to potty train, they're not trying to learn how to dress. They may have internalizing and, or externalizing problems. So you may see more hitting, biting, kicking or just being withdrawn. And they may have lower interaction that they just don't have the ability to deal with others. They didn't learn from how to self regulate, go back here. They didn't learn their self regulatory and stress coping skills, not even the basics when they were infants. So now being in the presence of other people can feel overwhelming. Cognitively they tend to show less creative play and problem solving and again more cognitive difficulties. School age children behaviorally. So now we're talking kindergarten, elementary school. They may have impaired adaptive functioning, continuing to have internalizing and externalizing problems. Affective and conduct Disorders academically, they may have more evidence or more frequent attention deficit hyperactivity and lower IQ scores. So we see that postpartum depression, because of the alterations in that attachment relationship and the infant and, and young child potentially having much, much higher stress levels, which we know alters brain structure, contributes to that adverse childhood experience, ends up having long lasting repercussions for the, for the child. So what can we do? Let's talk about screening. All new parents should be screened, even if it's not a first pregnancy. People can have one, two, three pregnancies and they go okay, and pregnancy number four, all of a sudden they start developing postpartum depression. The Edinburgh Postnatal Depression Scale is a great screening tool, real easy to use. Maternal mood in the immediate postpartum period or up to two weeks postpartum has been shown to be a significant predictor of postpartum depression. Again, I would argue that this is true for both care or all caregivers or both parents. Also watch for an upsurge in symptoms after discharge from the nicu. It can be really stressful bringing a baby home that had to be hospitalized, especially if it was hospitalized for a lot, a lot of, for a long period of time. We should be screening at every possible contact. Pediatricians should be screening. Obstetricians should be screening. Counselors if you're already involved with somebody, should be screening. Anybody who has contact with the parents should be screening. And that may even include, I would love it if daycare providers were even screening because some children start go have to start going to daycare as early as six weeks old. So that's really still well within that area where it's common for postpartum depression to start. 73% of women who met criteria for postpartum depressions that were screened in one study denied feeling sad. Could have been because of embarrassment or fear of judgment. Could have been because of lack of education about the negative impact of postpartum depression on the child. Or it could have been everybody just kept telling them, you've got the baby blues or you're just tired, you'll get over it as soon as you can sleep through the night. We do want to recognize that fatigue is a symptom potentially of postpartum depression. Causes of PPD hormone changes. If you've watched some of the other presentations that I've done on the hypothalamic pituitary gonadal axis or the HPG axis, you know that alterations in sex hormones, testosterone or estrogen progesterone can, we can and do impact the availability of neurotransmitters, including serotonin, dopamine and norepinephrine. So there can be hormone changes after birth? Well, there are. We know this. And when stopping breastfeeding, there's also hormone changes in the non birth parent, you know, whoever it was that didn't actually give birth, when the baby comes home, you know, having a new baby introduced into the home. And there have been a few studies that have even looked at families that adopt an infant and they've seen that there are some, not nearly to the extent, but there are some alterations in gonadal hormone levels and in new, even new adoptive parents. Lack of sleep or circadian rhythm disruption, we know, increases HPA axis activation, alters the availability of gonadal hormones and will alter the levels of neurotransmitters. Pre existing anxiety or depression issues. We talked about that. History of abuse or neglect as a young child. Bringing home a baby can trigger trauma. Memories can trigger all kinds of things that the person may have thought they dealt with and discovered, oh, this is rearing its ugly head again, or they may not have even realized existed and they start having flashbacks and things that they don't really understand. We need to recognize that holding this child that they're now responsible for may trigger a switch in their brain that says, you know, how could my caregiver have abused me? You know, look at this little precious helpless infant. How could my caregiver have done something so horrible to something so innocent? And there can be a lot of anger that comes up. Maternal illnesses, particularly autoimmune based illnesses like lupus, fibromyalgia, diabetes, chronic fatigue, and polycystic ovarian syndrome all can contribute to the development of postpartum depression. It's more common in women with Lyme disease. And poor control of diabetes can cause symptoms that look like depression. So if the woman developed gestational diabetes and it hasn't, you know, resolved itself, that can contribute to depressive symptoms. So we do want to make sure that we're ruling out physiological causes that need to be addressed. Trauma and grief can also cause ppd. If the person had had prior miscarriages or stillbirths, that can trigger postpartum depression. If the person, heaven forbid, you know, when they have that miscarriage or stillbirth, that is still a postpartum depression issue, they can develop postpartum depression after a miscarriage or stillbirth. If the infant is premature, there is a lot of stress that goes along with that and a lot of guilt. A lot of guilt that goes along with having a premature infant. Birth defects can be another cause for guilt and postpartum depression because there's a lot more stress. How are we going to deal with it? What are the potential outcomes, et cetera. And a lot of times with miscarriage, prematurity, and birth defects, people are looking for somebody to blame. And unfortunately, sometimes that blame comes back on the birth parent. And it's important to educate the parents about, you know, what happened, you know, talk to them about, you know, for example, prematurity, how common it is. And, you know, sometimes we. They still don't know what causes it, or they would be able to treat it a lot better. Birth defects, you know, sometimes there is no identifal identifiable cause. There's nothing that the birth parent did that caused it. Now, sometimes is, in the case of fetal alcohol spectrum disorders, there might be, and they're going to have to deal with, cope with that. The grief and guilt that might be associated with that. C section. Difficult birth can cause depression because of an increase in stress hormones, but also because it wasn't the birth experience that the person had dreamed of. And that could cause them to have some grief over not having that experience and sometimes can trigger more depressive feelings. And lactation difficulties can contribute to a caregiver feeling inept. You know, this is one of the most natural things in the world. How is it that I'm not able to do it effectively? And a good lactation consultant can help the woman navigate any lactation difficulties. But we do want to hear what that means to the woman. You know, if they are not able to effectively breastfeed with, what does that mean to them? And, or, you know, and sometimes it's not them, it's the baby cannot latch, so they have to pump, and what does that mean to them? Lack of social support or intrusive social support can also increase stress, increase HPA axis activation, and increase the likelihood of postpartum depression for clients at risk. What can we do? Work with the family during pregnancy to optimize mental health for all. This includes, you know, obviously the birth parent, the birth parent's partner, and any children in the family. Let's figure out how to recognize this as a. As the next chapter. Children aren't necessarily always going to be happy about it, so we need to help them deal with their anger, their frustration, and they're not wanting another sibling. And try to help with family therapy, create an environment that's accepting of this new infant. We want to increase personal awareness of Stress levels and effectiveness at dealing with stress. As I mentioned, if a caregiver, especially the one that's holding the, the infant at the time. Gets gets upset, the more upset they get, the more upset the child gets. And I've shared with you all before, my, my son had gastric reflux when he was a baby and he had a lot of pain until they figured out what it was and got him on the right medication. And I had a tolerance of about 45 minutes of being able to rock and hold and try to console him and failing miserably where I could keep calm and keep my composure. After about 45 minutes I would notice my stress level, my frustration level starting to go up. It was at that point I had to do the handoff to his daddy and his father took over for a little while and we would do the baby swap back and forth when we were noticing that, that our stress levels were going up because we knew that would just increase his agitation. Now Pat brings up that we also do need to consider and there, and it is important not only the mental health of the humans in the household, but also potentially the dogs. And, and I, we're not saying that sarcastically, but dogs can feel very jealous of young children or they may not be as accepting of this new little thing that's in the household. So there are steps that can be taken to help the dog accept the new infant when it comes home. That's a whole different presentation. But yes, you're right, we do need to know that it's important to consider the, the four legged family members as well when we're talking about, integrate, integrating into the new family and yes, dogs. Gwen, you're, you're right, dogs can attack. So it's important to educate the family about infant safety around dogs. And you know, what do you need to do to make sure that your infant is safe around dogs and if there was, well, that's a whole different presentation, so leave it at that. But you're right, we do need to talk about every, every living thing in the family. We want to help them prepare for the new addition, address any concerns and develop a postpartum plan. And that means who's going to feed the baby when and how is it that we're going to help each caregiver get some decent sleep during, especially during like the first three months when the infant is needing to be fed every couple of hours. One thing that works especially for people who are at risk of postpartum depression is encouraging a combo of breastfeeding and pumping. So at least one of the late night feed feedings can go to the other caregiver. So each person is getting, you know, a good solid six hours, hopefully eight hours of sleep at some point multiple times per week. It's not ideal to not get it every night and it's not necessarily going to work for every family. But for some people who are already at risk for postpartum depression and anything that they can do to minimize their vulnerabilities for developing postpartum depression is going to be helpful. A weekly interactions or check in with a counselor to identify mental health and self care needs of both parents can be helpful. This can be a case manager. This can be a nurse at the ob GYN or the pediatrician's office. It would be hugely helpful if we did a better job of this in the US now one mnemonic is nest s that can help us remember what we need to advocate that new parents do. Pay attention to nutrition, exercise, sleep, time for self and that's more than just taking a bath by yourself. That means actually having an hour periodically to do something that is, you know, rewarding to you and support. This includes emotional support, parenting support for parenting that infant as well as other children, respite care. Getting the caregivers a break because 24 7, 365 is exhausting and it is important for them to be able to have periodic breaks and that can be really difficult for people who are have a lower SES and can't afford a, you know, a babysitter for four or five hours. Adult interaction is important now that we've adopted and sort of embraced zoom, that's a little bit easier because even though it's not, you know, in real life, sometimes just having somebody to video chat with that speaks in sentences and can tell you what they're thinking can really be helpful. And peer support. Most hospitals have a group for new moms that can be really, really helpful. And there's a lot of places that also have mommy and me classes, exercise type classes that can encourage bonding, peer support and all that kind of stuff. Interventions for postpartum depression can include pharmacotherapy for or electroconvulsive therapy. Not everybody is down with taking medication, especially if they're breastfeeding. So ECT is still an option. Psychoeducation, this is huge. This is hugely preventative if we can do it before it happens. But it's helpful if, even if the person already has postpartum depression to help them understand what's going on and make better choices to enhance Their recovery. So we want to educate about the causes of postpartum depression, the impact of postpartum depression. This helps increase motivation to, you know, get help. The importance of self care, treatment options that are available. Techniques to address scary or unhelpful thoughts, radical acceptance and mindfulness strategies. Cognitive behavioral therapy is still one of those gold standards that can be used to address unhelpful thoughts and those cognitive distortions like the baby is always crying or the baby never sees sleeps. You know, those extreme words, Some of those things that make can make parenting feel even harder. Helping people restate some of those things as well as. Let's focus on the behavioral part. Identifying. Okay, you've identified, you know, these are some thoughts that you're having. These are some things that are problematic right now. What can you do to address them? The behavioral aspect to help them feel less disempowered, to help them feel safer, to help them feel like a better parent. Bright light therapy has been shown to be somewhat effective for postpartum depression. And part of that is because when there's a new infant and you're up every three hours feeding, what have you, circadian rhythms just go in the toilet. I mean, there is no rhythm. And bright light therapy can help reset some of those circadian rhythms. Parent infant psychotherapy works directly with the parent and infant for about 16 weeks. It's actually a modality and observes the parent child interaction through direct observation as well as through video to identify concerns and worries that the parent has. Identify patterns of relating and behaving. This is a great time to identify maybe if the parent is having difficulty developing that attachment. We can identify specific instances and show them, you know, what we're observing. It can help support the parent to develop different ways to relate to their infant. If they're just not sure what to do or, or if every time the infant cries they just pop a, pop a paci in its mouth, you know, what else could you do instead? Because children have multiple needs, identify influences from the past that are impeding the parent infant relationship. Emphasis is placed on parents internal working models or representations of the infant in the context of their own caregiving history and attachment experience experiences. So in what ways is this infant bringing up stuff of yours from the past? In what ways does this infant reflect schema you have from the past? The aims of parent infant psychotherapy are not only to learn to identify and meet the immediate presenting problems in the baby. And that can include difficulty getting them to sleep or to eat or, you know, fussiness, high needs, whatever the issue is but also to educate the parent about the relationship needs in order to develop a healthy attachment and help the parent and child feel more positively about themselves and their interaction. This results in increased self esteem, improved parent child interactions with reduced prenatal parental stress and reduced parent infant conflict real quickly. Infl Infanticide Many women who commit infanticide have no diagnosable mental illness that precludes them from being aware of the wrongfulness of their actions. The exception may be in postpartum psychosis, but a lot of the people who end up killing their infants actually did not have postpartum psychosis. Questions to Screen for Infanticide have you felt irritated by your baby? Do you have significant regrets about having your baby? Does the baby feel like it isn't yours at times? Have you wanted to shake or slap the baby? Have you ever harmed your baby? Do you think the baby or you would be better off if the baby was dead? And do you have thoughts of harming the baby? If any of these are answered yes, you want to proceed with a more in depth diagnosis. Diagnostic Interview the exposure of infants to relatively low doses of antidepressants through breast milk must be just juxtaposed with that of untreated maternal postpartum depression. The benefits of breastfeeding for moms and infants are well documented. Sertraline and paroxetine, among other SSRIs, are the most evidence based medications for use during breastfeeding. Because of similar findings of undetectable infant serum levels and no reports of short term adverse events. Infant infants exposed to fluoxetine had higher medication levels, especially if exposed prenatally. Citalopram may lead to elevated levels in some infants, but more data is still needed. Effectiveness Strategies to reduce infant exposure to antidepressants have been suggested but not established. Some suggestions include discarding breast milk obtained during the peak serum level. It's important to watch for signs of adverse reactions in the infant including irritability, poor feeding or uneasy sleep if the mother starts taking a medication. Premature babies, those with impaired metabolite efficiency or those on anti reflux medications should be especially monitored for adverse effects. Benzodiazepines may be useful for as needed use for anxiety until SSRIs have taken effect or to address transient insomnia. Sudden opioid withdrawal for unborn babies can cause respiratory depression which can lead to the fetus not getting enough oxygen and may be fatal. Switching medication prenatally is usually not recommended because it can destabilize opioid abstinence. Neonatal abstinence syndrome refers to the withdrawal experienced by babies. Being born to opiate addicted women appears generally less severe following prenatal exposure to buprenorphine versus methadone. Levels of buprenorphine and methadone are low in breast milk and breastfeeding should be encouraged even for women on these medications. Levels of naltrexone, on the other hand, are still kind of unknown. Postpartum depression affects about 20% of women. Both the mother and partner should be screened for depressive symptoms regularly, not just once. While PPD can begin anytime between 20 weeks gestation and 40 weeks postpartum, untreated it can last years. Scary thoughts are often part of PPD and should be normalized with parents. Postpartum psychosis is ego syntonic and will not produce those scary thoughts because it's very logical and real to the woman. PPD prevention involves NEST s for both parents. Nutrition, exercise, self care treatments involve psycho education, cognitive, behavioral and or parent child psychotherapy. Certain antidepressants have been found safe to be used when breastfeeding and it's important that we recognize that there are a lot of triggers for postpartum depression and people at risk for postpartum depression should engage in early intervention and planning, ideally while still pregnant.