Postpartum Depression & Psychosis | Perinatal Mental Illness Awareness

I'd like to welcome everybody to today's presentation on perinatal mental illness including postpartum depression. I'm your host Dr. Donnisee Snipes. Today we're going to define postpartum depression, postpartum psychosis, postpartum PTSD, postpartum OCD, and identify risk factors, screening tools, and protocols, as well as explore what we know about some of the causes of these um mental health issues during the perinatal period. perinatal depression, which includes prenatal during pregnancy and postpartum depression. They recognized that it wasn't being diagnosed enough because too many physicians were not diagnosing unless it started like two weeks before birth or, you know, within a very short period after birth. And they started to recognize that that's not it. perinatal depression and depressive symptoms can have an onset much much earlier. We also have stretched the diagnostic criteria if you will um to within one year of birth. The DSM5 TR still does not recognize postpartum depression as a diagnosis that far out, but the American College of Obstetrics and G gynecology does. Thank God. Uh the DSM5TR also does not recognize postpartum or perinatal depression as a separate entity. Um which drives me absolutely baddy because it is very different in a lot of ways than not perinatal related depression, PTSD and um OCD. There are a lot of differences and we also need to recognize that this can be something that for for some people that has an onset during pregnancy or you know within a a year after birth and may remit and then may come back after uh if there's another pregnancy. Uh so we do need to be aware of that. They have found, the research has shown, and I'm getting ahead of myself, but the research has shown that there's this cohort of individuals that are especially sensitive to changes in hormone levels. And the drastic changes in hormone levels that take place when you get pregnant, when you give birth, and when you stop lactating can trigger depressive symptoms, OCD symptoms, anxiety symptoms in that cohort of people more so than others. um and they're not exactly sure what what makes somebody somebody part of that cohort, but it's real and it exists. Postpartum uh depression is diagnosed in approximately 10 to 20% of postpartum women with prevalence influenced by genetic, hormonal, psychological, and socio environmental factors. And we're going to talk about all of those. Postpartum depression is not a moral failing. It's not a failing as a parent. It's not a sign of some other significant mental illness necessarily. What we're looking at is the body's reaction to significant changes in a lot of these areas that a person's genetics may make them more or less predisposed to. Now, I said 10 to 20% of women are diagnosed with postpartum depression. I'm going to follow that up with 50% of women, they estimate, are going undiagnosed due to stigma. So, the prevalence rates of postpartum depression, not baby blues, but actual postpartum depression, could be closer to 40%. Let that sink in. That's almost every other parent may be experiencing postpartum depression. And I am saying parents not to be particularly politically correct but to recognize that perinatal mental illness or mental health issues, whatever you want to call them, can affect both the birth parent as well as the partner. whether it's a dad or a mom or what the partner uh and we do want to be sensitive to that. Um 50% of patients with postpartum depression receiving treatment experience depression for more than a year after childirth. Now this should make you scratch your head and go okay what the heck are we missing? Because if we have a client come into our office with depression, not perinatal depression, just straight up depression, and we're seeing them for a year and they're still experiencing significant symptoms, we're going to be thinking there's something else going on. And for a lot of these people, there is something else going on. And that's what we're going to talk about today. We need to look at the person holistically. Even NBCC and Jacob has started talking about whole person care instead of just mental health care. 30% of women who did not receive treatment were still depressed up to three years after giving birth. And it could be even longer, but the study cut off. It was a longitudinal study and it cut off at three years. So, we don't know if they continued to be depressed for another two, three, five years or not. But think about what it would be like to parent a child to have to try to have the energy to focus and deal and interact and be present physically and emotionally for a child during infancy through toddlerhood. Oh my gosh. I mean, that's exhausting. that is not for the faint of heart during those periods. And if the person is struggling to manage their depressive symptoms, it's all that much harder. Hormones and schedule may have normalized, but the consequences of the postpartum depression may still be ongoing. Three years later, you know, assuming the person's not still lactating. Three years later, their hormones have stabilized. Their body has healed. Their schedule is not as chaotic. They're not having to get up for 2 a.m. feedings. But the self-loathing, the guilt, the anger, the shame, the uh, you know, fill in the blank that the person felt and took on as a result of not feeling like they were able to parent, as a result of the criticism that they may have received for o from others for not being able to parent the way that they quote should. that lasts. The impact that it has on the relationship for that person, with their partner, with the child, with the other children in the household that may linger. There still m may be lingering resentment, guilt, regret, etc., which continues to stoke the fire of the depression, if you will. We were talking before class about how postpartum blues used to be or baby blues used to be the term that was used for everybody and that's not true. We have a continuum and we're finally starting to acknowledge that there is a continuum. Postpartum blues is relatively common and I know this statistic might kind of blow your mind. 14% to 76% of people develop or experience postpartum blues, which is characterized by mild transient depressive symptoms and dysphoria during the first days to weeks after delivery. What's going on during that period? Your hormones are trying to rebalance. You know, those first six weeks are a bugger. You're not getting good sleep because you're getting up to feed the child. A lot of people are getting up to feed the child every few hours. So, you're not your sleep architecture is just blown all to heck. Um, you're adjusting to having a new human in the household. You're adjusting to worrying about this new human. Both of my children were uh micro preeis and well, Sean was a micro and Haley I think was just a preeie. Either way, um they were somewhat medically fragile and when they came home, stressing about whether they were okay, stressing about all that stuff was just an underlying energy drain for me and my husband. Postpartum blues is real. They did find that depending on the culture, some cultures acknowledge the mild transient depressive symptoms and dysphoria as a quote normal part of the early postpartum period and therefore they don't diagnose it as an issue so to speak. Um, a lot of women uh who give birth and are experiencing postpartum blues or even postpartum depression often don't even res report that they're feeling depressed because they associate what they're feeling, the low motivation, the fatigue, the sleep changes, the feeding changes, the lack of motivation as just exhaustion from having a new baby at home. They don't don't recognize the depressive part of it. Postpartum depression core features include dysphoric mood, fatigue, often anorexia, which not not the eating disorder, but anorexia meaning just a lack of appetite. Some people go the other direction and they're just eating all the time. but feeding changes, sleep disturbances, anxiety, excessive guilt, and difficulty bonding with baby with or without suicidal thoughts for at least a month. And we need to recognize just like when we have a person with major depressive disorder, their symptoms, we have five people with major depressive disorder, all five of them may have a different symptom presentation. The core feature is that depression and hideonia sort of thing. But it's important to recognize again that some people will label that feeling of depression and low motivation anhido anhidonia as just I'm tired. You know, I'll get over it once I can get get some sleep. I'm tired. And we don't want to miss a diagnosis of postpartum depression when if somebody isn't reporting, yeah, I'm I'm depressed. Like postpartum PTSD is another issue that arises more often than you would think. Um, again, this is something we don't often talk about, but perinatal PTSD has a prevalence rate of 5 to 7%. That's that's pretty high. Um, it's not quite one in 10, but it's it's right up there. Like regular PTSD, it requires exposure to a serious threat to life or bodily harm for the person or the fetus or the infant followed by persistent hyperarousal, avoidance of trauma related stimuli and intrusive experiences. When my son was in the NICU, he was in there for about six weeks and there were other infants in the NICU that never had visitors. their their caregivers never came to see them, to feed them, whatever. They were just they were in their incubators and and that was that. Um it can be easy to be critical of that, but we want to step back and say, what is that behavior saying? uh for many people who don't have an ideal birth experience there can be symptoms of and people can develop what they now call perinatal PTSD people women who develop preeacclampsia pre-term birth incompetent cervix that's when your body wants to have you know get the baby out before it's fully done um emergency C-sections still birth, birth defects, medic medically fragile infants or brada cardia. My son, even before they let him out of the NICU, the goal for him, he had to be five pounds and he had to go a week without his heart stopping when he was eating. I'm like, come again. We're only having him go a week. I'd like his heart to keep going. Um, but he would when he would eat, he would what we call Brady down. His heart rate would slow and come to a stop basically and we'd have to tap his tap his feet and rub his back and stimulate him and he'd come back. That is stressful. That is traumatic. Um, on top of all the other traumas of having a a 29week baby. Uh so there's a lot of stuff that happens that can be overwhelming for the parents and we want to remember that the PTSD a lot of times perinatal PTSD can be if the mother's life is at risk or if the infant's life is at risk. If the there's a cord wrapped around the kid's neck and they're telling you, "We got to get this kid out through emergency C-section, his heart rate's decelerating." How powerless do you feel when you're there's literally nothing you can do? Either the birth parent or or the partner. Postpartum OCD. Like general OCD, perinatal OCD requires obsessions or compulsions or both which cause clinically significant distress. This has a prevalence of 15%. Okay, 15%. Let that sink in. And the reason that I'm highlighting this and I mentioned before class that with my son I had significant postpartum depression and postpartum OCD. Now I know back then we didn't call it this. We just we called it at best scary thoughts. And I was afraid to tell my doctor. I was afraid to tell my husband. I was ashamed of the things that were going on. And to this day, I've never really described in detail some of the images I was getting in my mind. But we need to in allow people to be able to talk about it without fearing that we are going to commit them or take away their baby or or something else. Unique to the perinatal period, perinatal OCD obsessions often center on infant harm. Aggressive intrusive thoughts of infant harm are often are are especially common in during this postpartum period. And and like I said back in when I was having my kids, you know, 25 years ago, we called it scary thoughts. But these scary thoughts are extremely egodistonic. We experience them and we're like, "Oh, that that ain't right. That's that's no, this is wrong. This is dangerous. I'm scared." That's good. Egoonic means that it's not psychotic behavior. It doesn't become psychotic until the person thinks, "Oh, yeah, that makes total sense." Uh, and we want to emphasize this to the people we're working with. Even if they haven't told us that they're having scary thoughts, we want to educate them about it because it does happen so often. And I hate to say normalize it, but that's what we're doing. We're saying this happens to 15% of people at least because we know based on the content of these thoughts, there's a lot of people who never say anything. You can use the dimensional obsessivecompulsive scale if you want something to want some sort of instrument, but ultimately if you do an interview with a client, you can get an idea and they can tell you if they're having intrusive thoughts. Postpartum psychosis on the other hand refers to a severe disorder beginning generally within four weeks postpartum according to the DSM with delusions, hallucinations and gross delusions or hallucinations or both and gross impairment in functioning. Postpartum psychosis occurs in approximately one to two out of every thousand deliveries or approximately 0.1 to 2% of births. It's not that common. The onset is usually sudden, most often within the two first two weeks postpartum. The specific timing of postpartum psychosis strongly suggests a biological basis because the postpartum period is characterized by profound endocrine, hormonal, immune, neuroanatomical, and physiological changes in the body as well as the brain. There's inflammation going on. There are hormone changes. The neurotransmitters are more or less available because remember as our gonatal hormones change and our thyroid hormones change, our the availability of our neurotransmitters also changes. So we got that soup that we try to keep in balance. It's all out of whack. Signs of postpartum psychosis include delusions or strange beliefs which are egoinonic. The person believes they're true and completely logical. They don't understand why other people don't get it. Hallucinations, seeing or hearing things that aren't there, feeling very irritated, being hyperactive, decreased need for or inability to sleep. and the irritation, hyperactivity, and sleep issues. The more someone is sleepdeprived, the more likely they are to start experiencing psychotic features. This is true in major depressive disorder as well as postpartum depression. But if somebody is starting to if they're not experiencing insomnia, if they have a history of bipolar and it seems like they're setting in on a hypomomanic or manic episode. Um, physiologically, there's a lot going on that can contribute to psychotic features, which is why we want to pay attention to changes in the person's presentation, in their activity levels, their sleep, paranoia, and suspiciousness. Those are kind of early signs of delusions, rapid mood swings, and difficulty communicating at times. The most significant risk factor for postpartum psychosis are personal or family histories of bipolar disorder or the person themselves having a previous episode of psychosis. This could be a psychotic disorder such as schizophrenia or major depressive disorder with psychotic features or again bipolar disorder. But if the person has had a psychotic episode in the past, they're at much greater risk uh for postpartum psychosis. Doesn't mean it's going to happen. It's just a risk. And we want to be prepared for it. We want to make sure that the family has a plan to manage it should it happen. Just like when I had my second child, we had a plan to manage my symptoms. You know, we worked with the doctor and had a plan to manage everything um in order to prevent it from happening, which took a load off both my husband and I because we were like, "Okay, we got this. We know what to expect and we're not going to be caught with our pants down this time. Clinicians, if the woman's thoughts are worrisome to you, but she feels that her thoughts make sense and everybody else must be the crazy ones, it's an emergency. She needs to be evaluated by a psychiatrist or a physician right now. So, let's go back to perinatal OCD and scary thoughts and why am I jumping back into this? I didn't want to spend a whole lot of time on postpartum psychosis because as counselors, social workers, family therapists, we're not going to do a lot to treat that. That is referred out to the psychiatrist until it gets stabilized. But we are going to be working with a lot of women um who and their partners uh who are experiencing scary thoughts and those scary thoughts to my understanding um the the perinatal OCD is unique to the birth parent but who knows what'll come out in later research. However, the partner who's trying to support the birth parent must be aware and understand that the scary thoughts don't mean that this person is a bad parent. Doesn't mean that the person has suddenly developed psychosis. They're just scary thoughts. Scary thoughts are a very common symptom of postpartum depression as well as perinatal OCD. Scary thoughts can come in the form of thoughts of what if eye or images. You close your eyes and you just see in your mind's eye something bad happening such as the baby falling off the changing table. Scary thoughts can be indirect or passive, like something might happen to the baby, or they can imply intention, where the caregiver actually envisions themselves harming the child. And again, a lot of clinicians when they hear that, they're like, "Whoa, this person's dangerous to their child." And they start ringing alarm bells. If the person is talking about it and saying, "This terrifies me. That's good. Egoistonic is what we want. And we want to help them figure out, okay, when you start having these images, these thoughts, let's develop a safety plan. What can you do? For me, with my first child, first thing I did was call my husband. And I put my son in his in his crib and I would go outside and I would call my husband until somebody could get there to be with me because I felt unsafe and I didn't understand what was going on. And eventually, you know, my doctor helped get me properly medicated and things evened out. But it was important to that we had a safety plan. So I knew that yes, I can be home alone with my my child and if this happens, I can I have a plan. I can call my husband. I can call this person and these are the steps we're going to take. That provides a lot of that takes off that extra layer of stress that can actually trigger intrusive thoughts. Egoiststonic scary thoughts. I know I've said this like six times now. I'm going to say it again. They are not an indication of psychosis, but do require developing a safety plan with the mother slashfamily. And again, the slashfamily means whoever is going to be there to help support the caregiver when they're having these intrusive thoughts. Scary thoughts typically focus on the baby but also can center on the caregiver or the partner. They can be intermittent or constant and may be com accompanied by compulsive behaviors such as checking. A lot of times the scary thoughts are not accompanied by compulsive behaviors which again is why the diagnosis of OCD is often missed because too many people think that in order to diagnose OCD the person has to have obsessions and compulsions. That's not true. And the obsessions, this uh obsessional thoughts, the intrusive thoughts are the what is prominent for a lot of people with perinatal OCD. Some examples of scary thoughts. I'm afraid I might stab the baby with a kitchen knife. I see myself driving off the road with my baby. I think my family would be better off without me. I see graphic violent things happening to my baby. or even I'm having sexual thoughts about my baby. We want to take these seriously. We want to talk with the person having these thoughts about how they feel about them. Is this something that you you want to do or is this something that pops into your head that is terrifying or repulsive to you? Help me understand where you're at. Um, and talking about them with uh talking about the thoughts with them is very common and very helpful. Scary thoughts can make the woman feel like she's a bad mother. It can increase feelings of guilt and shame and make the person and her supporters question her sanity. It's a good sign if the thoughts are worrisome. So we need to educate the patient and her supports, friends, family, um nannies, whomever that these thoughts are not about her capability as a mother. Toolbox for clients and there there are tools that we'll talk about that we can use, but it's important that clients have a toolbox so when they're home and they have these intrusive thoughts, they know what to do. The first sad is the pneummonic. Safety, acceptance, and distract. Get the child and yourself to safety. If you don't trust yourself for some reason, or if you're afraid of these thoughts, okay? Well, what are you going to do when you're afraid of something? You're going to get the heck away from it. You're going to get yourself and your child to safety. What does that look like? For some people, that may look like packing the kid up and going to the library where you're in public with other people so you know that both of you are safe. You're not going to do something there. Um, other times it may be they may call their partner um and put the child in the crib. Uh there are a variety of options, but what is safety going to look like so they can let go of that constant stress that oh my gosh, I'm having this thought. How am I going to make sure I don't act on it? Because that'll just fuel it. Acceptance of what's going on. I'm having this scary thought right now. It's not uncommon in the perinatal period. It can be caused by changes in hormones and everything else going on. Um, it doesn't mean I'm a bad parent. So, I'm going to accept it is what it is. I'm having this thought. I'm not judging it. I'm having this thought. I'm needing to take action. Okie dokie. And then encouraging the person to distract themselves. If they sit there and ruminate on it, they are often going to again fuel the fire, distract themselves, call a friend, um take the child and go to the library so you can read a book or do something where you're not focusing on is the child safe and what's going to go through my head next. After the thought passes, and this part's important, too, encourage the person to reassure themselves that they won't always feel this way. It's a common experience, and it's partially hormonally driven. You know, it's I'm not a bad person. Help them identify triggers and vulnerabilities that contributed. triggers. For example, being home alone with the child um may leave the caregiver feeling vulnerable, may leave the caregiver feeling like, "Oh my gosh, I don't have anybody here to make sure that I don't do something wrong, which can amp up their anxiety and increase their scary thoughts." What sorts of triggers? People, places, things. Generally, it's um being alone is a big one. Uh and then vulnerabilities. What things may be going on with that person like they're getting even less sleep. The child's been collicky and they haven't been sleeping much and their sleep's been really fragmented even when they have gotten it. that can again increase the stress response, increase anxiety and increase intrusive thoughts. We know that when we're sleepdeprived, when we're stressed, we have much more difficulty controlling our thoughts and managing our intrusive thoughts, parartum or not. Um, and it's only intensified during the um perinatal period. and encourage people to track the frequency, intensity, and the duration of the scary thoughts. How often do they occur when when you're home alone? This is you feel like this is a dangerous situation for you. You're afraid to be alone with the child. So, how often when you're home alone, does this happen? How intense are these scary thoughts? Is it just a fleeting thing or is it just wow, you know, technicolor and how long does it last? Is it something you you have the thought once, you shake it off and you go about your business or does that thought or image keep coming back into your head for 30 minutes? Have them identify that as they heal, as they manage this, as they recover, whatever word you want to use, the frequency, intensity, and duration will go down. And we want them to focus on that. They're not just going to magically wake up in a week and they're not having these anymore. It doesn't happen. It's not an onoff switch. We need to help them see gradual progress. All women and their partners should be screened for all pregnancies. Just because you had postpartum did not have postpartum depression in your first pregnancy doesn't mean you're not going to have it in your second, fourth, sixth, whatever. The Edinburg postnatal depression scale is still the preeminent um screening tool. Maternal mood in the immediate postpartum period or up to two weeks postpartum is a significant predictor of postpartum depression. My sense is because we're going to find you're going to learn in a minute that the hormones the gonatal hormones of the birth parent as well as the partner sync up in that postpartum period regardless of whether the partner is male or female. Hormones sync up. The maternal mood is partly regulated by those hormones. My sense would be future research is going to show that paternal mood or partners' mood in the immediate postpartum period is also a significant predictor of postpartum depression for them. We don't have that research yet, but I'm I'm kind of getting ahead of myself. We also want to watch for an upsurge in symptoms in the p in the birth mother or the part partner after discharge from the NICU if the child was in the NICU or after cessation of lactation. I used to joke that I had um insurance pay for a full-time nanny for me for the first two months that my son was alive because he was in the NICU. And yeah, I got got to had to go home to sleep and I would sleep through the night except for getting up to pump and you know, all that kind of stuff. But it really was hard leaving. Oh my gosh, leaving my child, especially the first couple of times I had to leave him in the NICU and go home. Um, broke my heart. Yes, my body healed faster than some because I was able to get more solid sleep for those first few weeks, but the mental stress was significant. And then when he came home, like I said, I was worried that he was going to stop breathing. um which caused an increase in anxiety, a decrease in sleep for both me and my husband and increased in irritability and all that other stuff. Even though our hormones had roughly reeregulated themselves, there was chronic stress that occurred with him. Um and we also see the same thing after cessation of lactation because again the hormones just change dramatically. As I mentioned earlier, there are a lot of people who deny feeling sad during this postpartum period even though they meet the full criteria for postpartum depression because they attribute what we call depression or sadness to exhaustion. They're like, "I'm just tired. Everybody's supposed to feel this way." Um, and we want to educate them that what we're seeing may not be the normative experience and make sure that they're aware of the impact of postpartum depression on the child. The difficulty bonding can create early attachment wounds. risk factors. Lots of risk factors. Physiological stress. People with hypothyroid are at a much greater risk of postpartum depression. Well, go figure. People with hypothyroid often present with depressive symptoms in clinic. Um even, you know, just straight up major depressive disorder. and we test them when we realize well one of the things driving your symptoms is your hypothyroid. That's the same thing in the perinatal period. You can have people who develop hypothyroid between four and eight months postpartum and start to experience significant depression. Most cases resolve spontaneously, but about a third of the women who develop postpartum hypothyroid will develop permanent hypothyroidism, which will need to be treated to help their mood, their energy, etc. We also see people with elevated T3 um I'm sorry reverse T3 I should have said um elevated reverse T3 due to physical stress and reverse T3 is sort of our thyroid break. It's our body saying there's too much going on. We need to slow down. So I'm going to basically tamp down the thyroid hormone so you don't have the energy. You got to rest. uh when the physical stress resolves the reverse T3 drops and the T4 and T3 start doing their stuff again. But we do want to explore is there physical or even psychological stress that is keeping the stress response activated that may be causing an elevated T3. Blood tests can easily tell this. This is not magic. gonatal hormone changes during postpartum and lactation for and post-lactation for both the birth mother as well as their partner. Um because again we're sensitive to each other's hormones, chronic pain and sleep deprivation. And the little two right next to sleep deprivation, it was just another really good article on the impact of sleep deprivation as a risk factor for postpartum depression. Sleeping three hours at a time, getting up, feeding the baby, going back to sleep, you know, doing that. And then h especially for people that have other children at home or who had to go right back to work, um they're not getting enough sleep. and that sleep deprivation very quickly creeps up and puts them at significant risk for postpartum depression. A history of mood disorders may put somebody at risk for PPD. Just because you haven't had a history of anxiety or depressive disorders doesn't mean that you're not going to develop PPD, but people with a history of them are at greater risk. As I said earlier, bipolar and psychotic disorder histories are risk factors for postpartum psychosis. Nutritional deficiencies and gut dispiosis, and we've talked about that a lot on on my channel, that gut microbiome also can contribute to postpartum depression. If the birth parent is well either one, um if they're not getting adequate nutrients, they're not ingesting them. Maybe they're eating junk food, they're not eating much, um or they are not absorbing what they eat because they're having a flare of IBS or who knows what. um nutritional deficiencies, especially folate and other B vitamins are especially uh implicated in being risk factors for postpartum depression. Likewise, if the gut microbiome gets out of whack, people can be at greater risk. Sudden gonatal hormone changes after birth induces depression-like and anxietylike behaviors and an altered gut microbiome in mice. Yes, it is mice and we are not mice. However, it makes us think that what's going on in the human gut microbiome when there are sudden gonatal hormone changes. Could we see similar behaviors? Maternal chronic illness, autoimmune disorders, which involves systemic inflammation, are going to put somebody at greater risk for depression as well as postpartum depression. Fibromyalgia involves intense chronic pain which is going to impair energy and and other things making it harder to be present to be the parent and when the person a lot of people in the postpartum period have some chronic pain. Well, pain issues that existed before the pregnancy are often intensified after the pregnancy for a variety of reasons. Lyme disease, chronic fatigue, polycystic ovarian syndrome um all are also been associated as risk factors for postpartum depression. And I'm not going to go deep into that because we've got a lot to cover. But I do want you to think about how the symptoms of these things can make it difficult to parent. Can be intensified when the body is undergoing huge hormone swings. Can be intensified when the body is under stress because the person's not getting much sleep. Um, sleep deprivation, nutritional changes, and hormone changes are triggers for flares of all of these things. And poor control of diabetes and or having insulin resistance can also cause symptoms that look like depression. We want to encourage people to keep an eye on their blood sugar. even if they didn't have gestational diabetes, keeping an eye on their blood sugar uh during that postpartum period. Those that did have gestational diabetes often are at higher risk for postpartum depression because of the insulin resistance. Intrapersonal stress, that's within ourselves. People um who have postpartum depression or people who had a difficult pregnancy may have reduced self-esteem due to pregnancy or delivery complications or perinatal mental illness. If they started becoming depressed when they were pregnant then or even before they were pregnant it may contribute to them feeling like they're a bad parent. They may have very strong critical selft talk about who they are and their ability as a parent and then perceived others what we think other people are thinking. And if we go to cognitive behavioral therapy, that's mind readading. But many new parents feel like other people are criticizing them for how they're parenting. And if they believe that everybody is thinking that they're a bad parent, um, then obviously they're going to start feeling rejected, feeling isolated, maybe being afraid to to talk out. If they're having scary thoughts, then a lot of times they will feel like they are bad parents and they'll be ashamed to talk about it. There's a lot of shame unfortunately that goes along with perinatal mental illness and we need to really bring that out into the open and say this isn't something to be ashamed of. This is something that's happening. Let's identify it. Let's talk about it. Let's address it because it is addressable. They may experience reduced self-efficacy. They don't know that they can fix it. They don't feel like they're capable of being a parent. They don't feel like they're capable of managing day-to-day life and difficulty asking for help. Interpersonally, risk factors for postpartum depression. If the parent or partner experiences a lot of blaming or criticism for what happened or what is happening, maybe they had a child with a birth defect. Maybe they had a child that was born addicted to drugs. Maybe they had a child that was born prematurely. Um, if they feel like other people are blaming them for what happened, then it sets them up to feel isolated, rejected, and increases the risk of depression. Blaming and criticism due to parenting differences. Now, this is not mind readading and assuming you're being criticized. This is mother-in-law or mother or whomever coming over going, "You ain't doing it right. Let me show you how you need to do it because you ain't doing it right." Which can lead people to feel helpless, hopeless, rejected, which can lead into postpartum depression. lack of support or on the other end of the spectrum, intrusive support where you've got people just showing up going, "Hey, I'm here for a week and I'm going to help you take care of the kid." And you're going, "Uh, no, you weren't invited." Either way can be extremely stressful. You're not getting enough sleep or you're not able to parent your child. Um, my husband tells this story periodically about how when we were in the NICU, there were different nurses that would take care of my son and there was this one nurse that I buted heads with. Um, and I felt like he was overstepping and I felt like he was um, well overstepping and and my husband was like, you know, that's his job. You need to back off when you get home. You can do it however you want, but right now we got to let him do his job. But it was really hard for me because I felt like some things should be done a certain way. Paternal postpartum depression prevalence that we know of is 18%. Now, how many dads or partners attribute what they're going through as postpartum depression? Um, how many of them attribute it as depression at all? And the answer in my experience, um, and this is just clinical and personal experience, that prevalence is pretty low. So the 18% that we know of are 18% who've reached out and said, "I need help. This is this has gone too far." Parental synchrony was reported for hormones including oxytocin, testosterone, and cortisol levels. If one parents oxytocin is low, testosterone is low and cortisol is low, then the other parents oxytocin, testosterone and cortisol may also be low. And they found that there are potential um evolutionary reasons why, for example, men's testosterone drops during this early uh postpartum period. But what do we know about testosterone in men? When it drops, especially if if it's a plummet, which often happens, some men develop feelings of depression. Having a special needs medically fragile or niku neonatal intensive care unit. Sorry, I didn't define that one earlier. Having a child who is in the neonatal intensive care is also an interpersonal risk factor for postpartum depression. You want to help that child. You feel completely helpless. You feel powerless. You have to sit there while they are being um while they're inserting a nasogastric tube. That used to Oh, I used to hate that. um and you feel completely powerless, which can increase feelings of stress, depression, and hopelessness. All of these things we want to open up and talk about with our clients. Uh interpersonal risk factors that are more prominent for partners, maybe changing roles and responsibilities, feeling excluded when the attention is on the new baby. And this can be true for the kids in the house too. And missing the sexual relationship. A lot of partners feel neglected during the postpartum period. Other children may also feel abandoned, jealous, or resentful of the new baby, which can add additional stress or guilt to parents. The children have changing duties. They may need to help out a little bit more and they're going to get less attention because we got to divide it among, you know, the infant needs a lot more attention sometimes than um the child who's used to having the parents undivided attention. These are issues that hopefully we can help people plan for ahead of time and ease this transition for the children. Emotional and cognitive risk factors. As I mentioned, a history of mood disorders. Women who have experienced postpartum depression, have a 50 to 62% risk for future depression. people who have a history of trauma and grief, even if it doesn't rise to the level of PTSD, from adverse childhood experiences, prior miscarriage or still birth, prematurity, birth defects, C-section, uh lactation difficulties, which can be very demoralizing for a lot of women who are told that they should breastfeed. and every every person can breastfeed and it's natural and you just have to be patient. No, sometimes it just doesn't happen. Um, my son, as I mentioned, got fed with a nasogastric tube for the first six weeks. He wasn't willing to work to nurse. He wanted food. He actually had this hand signal. He would do this the entire time he ate. This was what we would say, more, more, more. you couldn't shovel it in fast enough. Um, and so lactation, you know, actual breastfeeding for him, just wasn't in the cards. And, um, I felt bad about that for a little while and then I got over it. But there are a lot of professionals that will shame mothers and we need to stop that. Um, high levels of chronic stress and feeling unprepared or lacking in knowledge to care for the child is another risk factor. It's like, okay, I don't know what to do with this little thing. Environmentally, feeling overwhelmed at the financial and care obligations, having a lack of space, or other young children at home, especially prechool children. Why pre-reschool? Because they don't go away. With children who go to preschool, kindergarten, regular school, they're gone for a few hours, so you can get some sleep. But with children who are pre- preschool, plus having an infant in the house, the thought of actually getting a nap during the day goes down to virtually nothing. Prevention and early intervention. work with the family during pregnancy to optimize mental and physical health for all Nest S. And we're going to talk about what Nest S is or nests is in a minute. Will increase personal awareness of stress levels and effect improve their effectiveness at dealing with stress. The less underlying stress they have, the more energy they free up to deal with the baby, the child, and life. help them prepare for the new addition, whatever that looks like. Address any concerns and develop a postpartum plan. We do want to encourage breastfeeding or combo breastfeeding and pumping for late night bottle feeding, but we don't want to shame the decision to use formula. Why encourage breastfeeding? They found that encouraging breastfeeding does or breastfeeding does serve as a buffer uh for postpartum depression. It helps slow the dump of gonatal hormones. It also increases oxytocin, but it may just not be in the cards for a lot of parents. Uh kangaroo care can be a very good alternative for people who can't or don't want to breastfeed. and that skin-to-skin contact with the infant for as long as you can every day. Weekly interactions or check-ins with a counselor to identify mental health and self-care needs of both parents can be super preventative. The nest's protocol, I didn't come up with it, emphasizes educating and empowering, supporting the family in accessing adequate nutrition, exercise, sleep, time for self, and support. And I will define support to include emotional support. We all need it. Some days we're just like, "Oh my gosh." um parenting support and education. My child is doing this. Is that normal? What do I do? How do I handle it? Respit care. Sometimes you just need a break because the child is collicky or be for whatever reason you just need a break. Where can you find that support to get respit care? Adult interaction. Having somebody that actually speaks in sentences is actually needed. it's necessary and peer support. Other parents with kids of the same age who have the same issues so to speak um you know like other NICU parents can be really helpful. Phicotherapy or electrocombulsive therapy has been shown to be a an option for addressing postpartum depression. And some people grimace when they hear pharmarmacothotherapy in the postpartum period. But we want to weigh the risks and benefits and the person can do that with their prescriber. What are the risks of pharmarmacotherapy versus the risks of postpartum depression to the child. Psychoeducation about the causes and vulnerabilities for perinatal mental illness. all the things that we've talked about the impact of perinatal mental illness on the infant and caregiver. It's not just a one-way thing. If I have postpartum depression or postpartum OCD or PTSD, it impacts me and my feelings about myself as a good mother. the importance of self-care, mindful awareness of how you're feeling, what you're needing in the moment, and the ability to focus on hardiness, what's important in your life, and how to use your limited energy to address the things you can control. Treatment options if they're needed, and techniques to address scary or unhelpful thoughts. Parent infant psychotherapy works directly with the parent and infant for about 16 weeks observing their interaction either directly or through video to identify concerns and worries, identify patterns of relating and behaving. So sometimes you may have a caregiver who doesn't pick up on the child's clues that they're getting overstimulated. Parent in infant psychotherapy can help with that. supporting the parent to develop different ways to relate to their infant. Identify influences from the past that are impeding the current parent infant relationship and placing an emphasis on parents internal working models or representations of the infant in the context of their own caregiving history and attachment experiences. How am I relating to this infant based on who I am and who I see this infant to be? The aims are to learn to identify and meet the baby's immediate needs. Educate the parent about the relationship and how to develop healthy attachment, consistency, attention, responsiveness, encouragement when it gets older, and safety. and helping the parent and child feel more positively about themselves and their interactions. They found that parent infant psychotherapy increases self-esteem, improves parent child interactions, reduces parental stress, and reduces parent infant conflict. Postpartum depression affects 20 to 40% of women and up to 25% of men, depending on the study you look at. Both caregivers should be screened for PPD. While PPD can begin anytime between 20 weeks gestation and four weeks postpartum, untreated it can last years. Now, obviously the four weeks postpartum is the DSM5 TR cutoff, but we look at it for up to a year. Scary thoughts are often thought of as part of PPD or perinatal OCD and should be normalized with parents, families, and other providers. their doctor, their OB/GYN. Um, so it doesn't get pathized. Postpartum psychosis, delusions, and hallucinations are egoonic. Postpartum depression prevention involves nests for both partners, nutrition, exercise, sleep, personal time, and support. Treatments include psychoeducation, CBT and/or parent child parent infant psychotherapy. There are many triggers for PPD and people at risk for PPD should engage in early intervention and planning while still pregnant. Are there any questions? the handout um or the PDF of this PowerPoint is included in your classroom, so you have time to look at it. And I did include a bunch of articles that are part of the 16-hour course for postpartum depression in case you wanted to peruse it. Not everybody wants to take a 16-hour CEU course on postpartum depression. Um, and so if you just want the information, not the CEUs, you can look it over. I thought it was important enough to include it in in your classroom. Um, but yes, there is a 16-hour ondemand course that goes in depth into postpartum depression, postpartum psychosis, and working with families who have an infant that is in the neonatal intensive care unit, has birth defects, or is medically fragile. some of the things and I'm just as I'm watching y'all leave and waiting to see if there are any questions. Um, oh, somebody said, "Will I offer additional perinatal trainings?" Um, I don't have any scheduled for the lives, but I do have the on demand. uh courses that are available for you. Um some of the interventions that can help. My husband um happened to be on night shift when our children were born. He was able to kind of stay on night shift, if you will. When he would come home, um he would take the middle of the night feeding. So, I was able to get a solid six, seven, sometimes eight hours of sleep, which at if you've taken been with if you've been with me for very long, you know, sleep is really important for me. And definitely in the postpartum period, it was super important. And that allowed me to get the sleep I needed. Um, and he was able to uh feed the baby and and do that kind of stuff. that was a huge help. Um, as I mentioned, he was always there for me to call on the phone. Thankfully, his supervisors were very family first and were accommodating when I had my initial um perinatal OCD crisis until we got that diagnosed and treated. Everybody, have an absolutely wonderful rest of your week and I'll see you next Wednesday.