Podcast: Understanding Postpartum Depression and How to Support New Moms

Dr. Osborne: I think loved ones are such an important part of the equation, and I think everybody who is in the village of a new mom, whether it's her partner, her in-laws, her neighbor, everybody should feel empowered to help a woman reach out.

Courtney Allison: Welcome to Health Matters, your dose of the latest in health and wellness from NewYork-Presbyterian. I'm Courtney Allison. [upbeat music] This season on Health Matters, we're covering your health from A to Z, asking our experts to break down the health topics and wellness trends we're all curious about. Today, we're at W for women's health. Specifically, we're focusing on postpartum depression. While many women may feel the baby blues after giving birth, how can someone tell when those feelings are something more serious?

We spoke to two women's health experts from NewYork-Presbyterian and Weill Cornell Medicine, Dr. Rochelle Joly, an obstetrician and gynecologist, and Dr. Lauren Osborne, an obstetrician and gynecologist and reproductive psychiatrist. They share what might be driving perinatal mood disorders and what to do about them. Dr. Joly also discusses her work developing an AI tool to help predict who is at risk for postpartum depression, and we learn what we can all do to better support new moms.

Dr. Osborne, Dr. Joly, thank you so much for joining us today. Welcome to Health Matters.

Dr. Joly: Thank you for having us.

Dr. Osborne: Great to be here. Thank you.

Courtney Allison: We've heard the term baby blues. How is postpartum depression different from the baby blues?

Dr. Osborne: Postpartum depression is a psychiatric illness. It's an episode of depression that arises in the postpartum period. Baby blues, by contrast, is something that happens to almost all women. It's an emotional volatility that arises, probably directly related to the hormonal changes that occur across the childbirth transition, and something like 80% of women will have these symptoms. It's emotional volatility, as I said, crying unexpectedly, even laughing unexpectedly. It happens to most women. It goes away within a couple of weeks, and it's not associated with severe symptoms such as suicide or functional impairment. Postpartum depression affects a much smaller number of women, probably about 15 to 20% of women, but it's associated with more functional impairment, it lasts much longer, and it usually doesn't get better without treatment.

Courtney Allison: Dr. Joly, how common is postpartum depression, and is it an underdiagnosed condition?

Dr. Joly: As Dr. Osborne said, postpartum depression probably affects 15 to 20% of the population, but we know from many studies that we see about a 7% prevalence. There are many people who are not diagnosed, whether it's related to stigma or whether they are also lost to care in the follow-up in the peripartum period, or may not be seen for a full year after they deliver. Additionally, people are afraid sometimes to admit that they're having symptoms related to depression because they may have a fear of bias or the unknown. They don't know what it means when they admit that they have postpartum depression or any symptoms that are not utter joy. You also asked about postpartum blues. A lot of postpartum depression may mimic postpartum blues, and so people might just think, "Oh, it's normal to be extremely tired or crying when I'm postpartum." And so people might not understand that what they have is a dysfunction as opposed to just a normal reaction to delivery.

Courtney Allison: Well, you said something like, "If there are feelings other than utter joy," and I imagine it is complicated after the birth of a child. It's not going to be just joy. Could one of you share what are some of the signs that postpartum depression may be developing, both for new mothers themselves that they might spot or maybe that their loved ones might see?

Dr. Joly: Patients could be reporting that they just feel sad, that they don't want to get out of bed. In the extremes, if they feel like they don't want to live or they're daydreaming about ways to not live anymore, these are all reasons why we would refer people to a psychiatrist or think about starting some kind of medication beforehand. Also, often on high alert, maybe someone who struggled with a very severe depression before pregnancy or during pregnancy.

Dr. Osborne: From my perspective, a lot of people with postpartum depression have a lot of anxiety. There's a high comorbidity between depression and anxiety generally. In postpartum depression, three out of the known five clinical phenotypes of postpartum depression have the word anxiety in them, so anxious features are going to be a really big part of it. And we often see women who have difficulty with sleep. Now, nobody gets a lot of sleep in the postpartum. You have a new baby. But women who aren't able to sleep when they have the opportunity to do so, that's a red flag in the postpartum. And that prodrome of anxiety and insomnia not only is a hint that there may be postpartum depression going on, but in addition, we have to have our ears up when we hear anxiety and insomnia to also be alert to a much more serious illness, postpartum psychosis. For me, a real hallmark of somebody who's ill in the postpartum, whatever the diagnosis is, is that level of functional impairment, right? If somebody's not able to do what they need to do as a mother, as a partner, as a worker, that's a sign that there's a psychiatric illness that we need to be alert to.

Courtney Allison: And you mentioned postpartum psychosis. Can you share more about what that looks like?

Dr. Osborne: Postpartum psychosis is the most serious illness that we have in the postpartum. It affects a much smaller number of people. So postpartum depression, we said, was 15 to 20%. Postpartum psychosis is more like 0.1%. It is a mood disorder that's also accompanied by psychotic features. Its onset is usually very early in the postpartum, so usually within the first four weeks, but certainly within the first 12 weeks. Very many people with postpartum psychosis will go on eventually to be diagnosed with bipolar disorder, although that's not true of all women. It is very scary because it has high rates of suicide and infanticide, and the woman may well be a danger to herself or to others. So somebody with postpartum psychosis needs emergent psychiatric evaluation and likely needs inpatient hospitalization.

Courtney Allison: Do we know what causes postpartum depression? Does it have anything to do with all the hormonal changes, the life transition? I'm sure lack of sleep doesn't help anything.

Dr. Osborne: As with every psychiatric illness, it's multifactorial, right? These are illnesses of the brain and the mind. So there are psychosocial things that may result in a presentation of postpartum depression, your conflict with your partner, stress at work, lack of sleep, housing or food insecurity, all of those things. And then in addition, there are biological vulnerabilities, and yes, it's related to the hormone shift. But what we have to remember is that every woman who gives birth undergoes that shift, and not every woman develops postpartum depression. So it isn't the levels of the hormones themselves. It's individual vulnerability to that change, to the fluctuation or shift, and that's where a lot of the biological research is centered right now on what makes up that individual vulnerability. There may be genetic components that make it up. It may be changes in other systems like the immune system. And so we're still trying to untangle that, so you can't directly say, "Oh, it's because of those hormones," right? The hormones are related to it, but it's not solely that.

Courtney Allison: Could we spend a little time talking about what factors can increase someone's risk for developing something like postpartum depression?

Dr. Joly: I think the number one is a prior history of depression and mood disorders. Other things that we see that are well known are socioeconomic disadvantages, partner violence, food insecurity. Also know now that there are additional risk factors that may develop during pregnancy such as vaginal bleeding, preterm contractions, hypothyroid. All of these things that come up during pregnancy can put people at increased anxiety or stress and cause depression or trigger something that may have been there before.

Dr. Osborne: We also know that there are certain biological factors that put people at risk, and we're learning more and more about that as research continues. But the two main types of research that are going on in this area are research into hormone metabolism, how much progesterone is metabolized across pregnancy, progesterone being the major hormone that supports the growth of the pregnancy, but it's metabolized down into molecules that affect the brain, and how the balance of those metabolites changes across pregnancy affects the functioning of the brain and may put people at risk, and there may be people who have abnormalities in the way that system works. We also see a lot of huge changes in the immune system across pregnancy, and we have substantial evidence that malfunctioning of certain immune system proteins during pregnancy may also predict who's going to be at risk in the postpartum. So, lots of exciting work being done in that area that sort of goes along with those psychosocial risk factors that Dr. Joly mentioned.

Courtney Allison: That's so interesting. And Dr. Joly, I'd love to hear about your research with this AI tool that can help clinicians predict postpartum. Can you share more about that?

Dr. Joly: Yes. So, in 2019, the Department of Informatics launched a project led by Dr. Yiye Zhang and Dr. Jyoti Pathak, where they developed a risk prediction model that could find patients that were at risk of developing postpartum depression. And the way that they did it is that they fed the model many patients who already had a known diagnosis of postpartum depression, and then it detected which variables would put the patients at risk of developing depression, and then they validated it on over 15,000 patients in our hospital, and then outside the hospital, over 50,000 patients. And, the model is now integrated into our electronic health system, and we just launched a project where we are rolling it out with clinicians to see if it is helpful, if it changes management, if it can highlight who is at risk and help identify patients sooner and advise them on additional resources that may be available.

Courtney Allison: And so once a patient is identified as being at higher risk, what happens next? What kinds of support or treatment are available?

Dr. Osborne: We've had the rise of collaborative care models, which is a model we're using here at Weill Cornell, where we have a team-based approach. So there are behavioral health clinicians who are social workers, psychologists, nurse practitioners embedded directly in the obstetric practice. All of it is overseen by a reproductive psychiatrist, but it enables us to determine which patients might just need a little bit of supportive therapy, which other patients might need to be started on prophylactic medications, which other patients might need to be elevated directly to a reproductive psychiatrist because their illness is more severe.

Courtney Allison: So if someone's struggling and it's persisting and they're having trouble functioning, what's the first step they should take to try to get help?

Dr. Joly: If they are enrolled in prenatal care, they should absolutely call their clinician. They shouldn't feel that they are alone.

Dr. Osborne: If they're struggling and they're not connected to obstetric care, like maybe it's far out into the postpartum, they haven't seen their doctor for a while, they don't have somebody that they can call readily, Postpartum Support International is a great place to start because they have support groups, and they can help you connect you to resources in your area. They're in all 50 states plus internationally. We also have a maternal mental health hotline, so that's a number that you can call anywhere in the country and be connected to resources. I completely agree that going to a person you know and who supports your care is by far the best thing to do, but for anybody who doesn't have that option, those two options are really good places to start as well.

Courtney Allison: Thank you. These are really good tips. Something I saw when I was reading an article about postpartum depression ahead of the interview, in the reader comments, a woman shared that she was really struggling after the birth of her child, that she almost couldn't even make the call herself, and I think her father-in-law stepped in and was like, "I found a therapist for you. They're waiting for your call. I'm calling you in 10 minutes to make sure you've called them." So I'm wondering, how can loved ones support someone who appears to be struggling?

Dr. Osborne: I think that's such a powerful story, and I think it's so often true, because first of all, if somebody's really suffering and she's not functioning, she may not be able to make that call. But she also may not recognize the depth of her suffering. She may think, "This is normal. This is what it's like to be a mom." So I think loved ones are such an important part of the equation, and I think everybody who is in the village of a new mom should feel empowered to say, "Hey, I think you need help," and to help a woman reach out. You know, it takes a village. You can't rear a baby on your own, and women cannot identify or get appropriate treatment for something like postpartum depression if they don't have people around them supporting them. And I think one area where loved ones can make a really big and critical difference is in sleep. We've mentioned before insomnia being one of those red flag symptoms that puts us on high alert, and women not being able to sleep when they have the opportunity to sleep is a real red flag. Also, women who are choosing not to sleep, so women whose anxiety is making them get up and check the baby multiple times. You know, when we used to have paper prescription pads, I used to write a prescription for sleep. I would really encourage loved ones, before the baby's born, for a partner or whoever's supporting that woman, a sister, a mother, an aunt, whoever, to have that conversation of, "How are we going to protect your sleep in the postpartum?" Because it's crucially important, and that's something that people can be proactive about and say, "We know this is an issue. We know that women who have worse sleep at one month postpartum are more likely to have postpartum depression a couple of months later." So there's something that we can do together as a team, as a parental team, to stave that off.

Courtney Allison: I love that you put it on a prescription card. It just speaks to the importance of sleep and trying to prioritize your sleep. Is there anything you can do to prevent postpartum depression?

Dr. Osborne: Great question, and one of the things I'll say is that we have a serious lack of research in terms of prevention, in terms of pharmacologic prophylaxis. Like, we don't really know. We have this new medication for postpartum depression that's rapid-acting, but we don't have any research showing us if we give that at childbirth, are we going to prevent postpartum depression? We do have a lot of evidence in non-pharmacologic things that you can do to prevent postpartum depression, particularly if somebody's had a prior experience of depression, making sure that they're in good psychiatric care, they have a therapist who's giving them emotional support, prenatal yoga, exercise, getting plenty of sleep. All of that is going to help prevent mood disorders. But unfortunately, that is not something that everybody has access to, right? Psychotherapy is often outside of insurance. Going to prenatal yoga costs money, right? So there are known things that we can do that don't involve medications, but they aren't things that we all have access to. So I think it's a real dilemma.

Courtney Allison: Are there any myths around postpartum depression or perinatal mood disorders you'd like to debunk?

Dr. Joly: There is the old school thought where people would say, "Just snap out of it. Look at what you have." And it's easier said than done, whatever the mood disorder is, whether it's related to pregnancy or postpartum, and that's not really an option for a lot of people because there are chemical changes in their body, and they need to control that sometimes with medication, and people can't just snap out of it. For some people, it might be behavioral therapy, and for some people, it is resources or relationship status, and those need to be addressed.

Dr. Osborne: There is this myth that mental illness is something we should be able to pull ourselves out of, and I can't tell you how many times I've had the conversation with a patient and I say, "I think you need this medicine. I think it's going to help you." And they say, "I don't want to take medicine." And the analogy I use is, if I said today that you have gestational diabetes and you need insulin, how would you respond? She'd say, "Well, I'd take the insulin." And I said, "This isn't any different." But I think it's really hard for patients to even accept that because of the country's stigma about mental illness in general. They know they're suffering, they know they feel terrible, but they can't get over the notion that society has installed in them.

Courtney Allison: I think that's such a powerful example. Thank you. If you want listeners to remember one thing from this conversation, what would it be?

Dr. Joly: I would say that people should know that providers out there care. They should not be ashamed to tell someone, and it can be anyone. It can be a family member, a friend. It can be a clinician. I think that people should feel empowered to speak out and be heard.

Dr. Osborne: I completely agree with that. The message that I try to get across to people is that mothers are not just vessels for babies. Mothers are people, and mothers' illnesses need to be considered. And any mother who's ill, that's going to have an effect on the baby as well. So when we don't take women's depression in the postpartum seriously, we are affecting the health of the mother, of the baby, of the entire family. And how can we as a society progress and be a good and just society if we don't take care of the basic needs of those building blocks of our society, which are mothers and children?

Courtney Allison: That is so well said. Dr. Osborne and Dr. Joly, thank you so much for all your insight and such a powerful conversation on postpartum depression and supporting women and their families.

Dr. Joly: Thank you. Thank you for highlighting this.

Dr. Osborne: Yes, it's a great topic. I'm glad you chose to cover it.

Courtney Allison: Our many thanks to Dr. Rochelle Joly and Dr. Lauren Osborne. I'm Courtney Allison. Health Matters is a production of NewYork-Presbyterian. The views shared on this podcast solely reflect the expertise and experience of our guests. To learn more about the work Dr. Joly and Dr. Osborne do with patients, check out the show notes. NewYork-Presbyterian is here to help you stay amazing at every stage of your life. To hear every episode of Health Matters, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get podcasts.