Approximately 10-20% of women will experience some form of postpartum depression. Without prompt access to care and support, the wellbeing of both mother and child could be in jeopardy.
Dr Maureen Sayres Van Niel and Dr Jennifer Payne discuss working together in the field of women’s mental health at the American Psychiatric Association, as well as the many changes and challenges in women’s bodies during pregnancy and after birth, and how recognising and treating perinatal mood and anxiety disorders is essential to ensure best outcomes.
Read their original article: doi.org/10.3949/ccjm.87a.19054
In the US; call 1-833-943-5746 , or call the new emergency helpline on 988.
In the UK; call 111 , or text “SHOUT” to 85258 .
Image credit: Microgen/Shutterstock
Edited podcast transcript for Dr Maureen Sayres Van Niel and Dr Jennifer Payne
00:00:01 Will Mountford
Hello, I’m Will, welcome to ResearchPod. Amidst the many changes and challenges in women’s bodies, during pregnancy and after birth, are those related to their mood or anxiety.
Between 10 to 20% of women will experience some form of postpartum depression, meaning it is essential for doctors, families and mothers themselves to be able to identify the symptoms, risks and treatments available. Without accessing care and support as soon as it’s needed, the well-being of both mother and child could be in jeopardy.
Today, I’m speaking with Dr Maureen Sayres Van Niel and Dr Jennifer L. Payne, about their review article on perinatal depression in the Cleveland Clinic Journal of Medicine, which resulted from their work together in the field of women’s mental health at the American Psychiatric Association. We discuss how to recognise and treat perinatal mood or anxiety disorders to ensure the best outcomes for mother and child and how to use the 24-hour helplines that are available. Those US and UK helplines are also written out in the show notes for this episode, so if you or someone you know needs that support, reach out now. Dr Van Niel, Dr Payne, such a pleasure to have you here today.
00:01:16 Dr Maureen Sayres Van Niel
Good morning Will. Good to be here!
00:01:19 Will Mountford
If we could start please with Dr Van Niel, could you tell me and everyone listening at home, a bit about yourself, your current position and some of your academic history? Everything that’s led to our conversation here today.
00:01:31 Dr Maureen Sayres Van Niel
Sure, Will, it’s good to be here. It’s also nice to be here with Dr Payne, whom I met while we served as co-presidents of the Women’s Caucus of the American Psychiatric Association over many years. I’m a reproductive psychiatrist from Cambridge, Massachusetts. I trained in the Harvard Medical System and did three years of specialised clinical training and research as a psychiatrist specialising in women. I’ve practised reproductive and general psychiatry – done research, published articles and written news articles on women’s mental health for the past three decades. More recently, I served as a member of the US Department of Health and Human Services Committee on the prevention of women’s health disorders. As of today, I will begin serving a three-year term as a member of the Board of Directors of the American Psychiatric Association Foundation, which is the service arm of the American Psychiatric Association.
00:02:36 Will Mountford
And Jennifer a bit about yourself as well, please.
00:02:40 Dr Jennifer L. Payne
So, I’m also a reproductive psychiatrist. I spent close to 18 years at Johns Hopkins [University] and founded the Women’s Mood Disorder Center there, which was a clinical and research enterprise. And I just moved in the last year to the University of Virginia as the Vice Chair of Research. I’m a professor of psychiatry, and I’ve started the reproductive psychiatry research program there. I’m also President of the Marcé of North America (MONA) perinatal mental health society.
00:03:15 Will Mountford
From when you started your research, through today, is there anything that you’d say has been a special driver or motivation that’s kept you going?
00:03:23 Dr Jennifer L. Payne
My passion for my research really started when I did my fellowship at NIH [National Institutes of Health], many years ago. And we spent some time really talking about what the underlying biology might be for mood disorders. And what’s interesting is in my entire career, we still don’t really totally understand exactly what the broken part is, in major depression or bipolar disorder. And while we were having these discussions, I had an epiphany that postpartum depression would be something very interesting to study because it’s the only time that you can predict when someone will get depressed. So, if you take 100 women who are pregnant, from the general population, about 10 to 15 will get depressed in the immediate postpartum time period. If you take women with pre-existing mood disorders, about 40 to 50 of them will. And if you take 100 men and watch them for a year, none of them might get depressed. So, the postpartum time period is an increased risk for depression. And we can predict when that depression will happen, so we can actually study women before they get depressed and start to look at the underlying biology for postpartum depression.
00:04:37 Will Mountford
Thank you, and Dr Van Niel, if we could hear a little bit about the human behind the research?
00:04:42 Dr Maureen Sayres Van Niel
Sure. When I was doing my training, I noticed that there was no attention being paid to a woman’s special mental health condition. I was in a psychiatry residency, but there was no mention of the things that affect women only. And also, there was no concentration of research funding in this area at all. And over the course of the past three decades while I’ve been practising that has improved to some extent, but I think, as Jennifer will attest, the field of understanding women’s mental health is still in its early stages. And as we study and learn more, we realise how important it is to understand the differences between regular depression and that subset of depression that might occur during the perinatal period, both during pregnancy and postpartum.
I have seen hundreds of women with this condition. And as Jennifer said, it is a very frequent condition and that adds up to millions of American women who are suffering from these conditions. And I’ll add that it’s sort of a crisis: these conditions are not getting diagnosed right now, and, therefore, they’re not getting treated. With treatment, these conditions can go very well, but if they’re ignored, there can be serious consequences.
00:06:12 Dr Maureen Sayres Van Niel
So, what does it look like when somebody has this kind of problem? How do they know they have it? Contrary to what you might think, they are depression manifestations, but they also can manifest in other different ways, which I think are important to understand, as we try to understand this condition for both ourselves as women and also for family members who may be listening, who see the symptoms in a member of their family.
So, we all understand what depression is, like, you know, a depressed or sad mood, crying frequently, having less or more sleep and appetite than usual, feeling inertia. But in order for this to be considered a true depression, it must last for at least 14 days, be there most days, and result in some impairment of function. So, that’s an important distinction, I think. And if perinatal depression is severe, it may result in thoughts of the mother harming herself or the baby. As far as what the experience is like, one woman put it: ‘I felt like a fog of sadness settled over me, and I thought it would never leave. Some days I stayed in bed alone most of the day, and I couldn’t admit it to anyone.’
They’ve discovered recently that anxiety can be as common a disorder during the perinatal period as depression. And as one woman put it: ‘I love my baby with every ounce of my being, but my worries about him bordered on insane. I couldn’t let anyone else pick him up for months for fear he would get injured.’
Women can also experience physical symptoms. Sometimes for the women I’ve treated, their emotional pain was felt like physical pain, like back aches or stomach aches, or they felt actual panic attacks. One woman described that she felt like she was having a heart attack with short breathing and rapid heart rate. She said ‘I would go into the baby’s room while she was napping 10 or 15 times an hour just to be sure she was okay.’
00:08:34 Dr Maureen Sayres Van Niel
Interestingly, a woman can also feel very numb and disconnected. This is very important to understand because this can also be a manifestation.
One woman said ‘I felt numb, there was no joy and sadness and no feeling for the baby. I felt disconnected from myself and others. It was like standing at the bottom of a well, looking up at the circle of light where people were having normal happy lives. And I couldn’t climb out. I wanted so badly to feel like the other mothers, but I couldn’t.’ A lot of women feel guilt during pregnancy, that they’re not a good enough mother. But these women can sometimes feel excessively guilty and feel constantly like they’re not enjoying their motherhood the way they should. One woman said ‘I feel guilty for not bonding with the baby and actually not wanting to be with her.’
And finally, something I think that we all should recognise is that these conditions can manifest themselves in a great degree of anger and irritability. Some people describe a kind of anger and irritability they just can’t control. One woman said ‘I resented having a baby. I thought we made a terrible mistake. I was angry all the time with my partner and all my relatives.’ So, those are some of the main ways, Will, that we see this manifest itself in women.
00:09:48 Will Mountford
So, for the social concept of the ‘baby blues’, but also, as Jen mentioned – there are differences between people who are depressed before pregnancy, during pregnancy, and afterwards – for all of those experiences, different conditions, is there an underlying physiological change in the brain to give any of those condition’s specific characteristics?
00:10:12 Dr Maureen Sayres Van Niel
So, it’s a very important point to bring up the baby blues because I think many women know that in the first week or so after pregnancy, even in the first two weeks, you often feel weepy and sort of intense emotion. And it can be very, very prominent – and that can occur in about 60 to 80% of women. But the symptoms are only present usually for one to three days. And they’re not something that takes over your life like this condition. Postpartum depression lasts two weeks or more, and the symptoms are present on most days.
00:10:56 Dr Jennifer L. Payne
So, in terms of whether there is a change in the brain – we suspect there is. And we have some evidence that there is. First of all, postpartum depression has a genetic basis. So, it seems to run in families with major depression and bipolar disorder. There appears to be a genetic vulnerability to developing postpartum depression episodes.
In addition, my research has identified what are called epigenetic biomarkers of postpartum depression. So, I can actually take blood from a woman during pregnancy and if a woman has these epigenetic biomarkers they’re about 80% accurate in predicting that she will become depressed in the postpartum time period. Also, in some of my more recent work, we’re starting to look at what’s called neurosteroids. So, neurosteroids are chemicals in the body that affect the brain. And we’re finding differences in women who go on to develop postpartum depression. So, it looks like there’s a real biological vulnerability to the development of postpartum depression. That being said, we also know that stress and other psychosocial risk factors increase the risk for postpartum depression.
00:12:15 Will Mountford
And are those markers for just the sheer rate of incidence or also for the severity of incidents?
00:12:21 Dr Jennifer L. Payne
That’s a great question. It’s really the rate of incidence – so, will you become depressed or not? We don’t have a marker for severity.
00:12:32 Will Mountford
And then I suppose the next big question is, well, if this is happening, how is it detected? How is it screened for and how is it treated? Catching it early is going to be the best-case scenario.
00:12:42 Dr Jennifer L. Payne
Sure. So, it’s interesting because we only screen about 40% of pregnant women for depression in the perinatal time period. And postpartum depression is actually the most common complication of delivering a baby. In contrast, we screen 99% of all pregnancies for gestational diabetes and that has a rate of about 6%. And so, we can really be doing much better for screening. I’ve talked about the biomarkers we have; I’m hoping that someday we’ll be able to develop that into a blood test. That being said, we don’t have that yet. But screening can be really simple – it’s called asking questions. And so, OB-GYNs [obstetrician-gynaecologists] can screen using something called the Edinburgh Postnatal Depression Scale, or there’s another scale called the PHQ-9 or a PHQ-2, which can screen for symptoms of depression. And then the patient and her doctor can have an ongoing conversation about whether she’s feeling depressed, whether she has a history of depression and whether she becomes depressed in the postpartum time period.
00:13:56 Will Mountford
The big lingering question there is, well, we’ve got these tools, so why isn’t this getting diagnosed?
00:14:02 Dr Maureen Sayres Van Niel
Yes, that’s such an important question to ask because, first, there is the problem, as Jen referred to, of having doctors and officers actually screen for this problem – that’s primary – but there’s also a reluctance on the part of the women to come forward and to say that they’re suffering or that they’re having a problem.
You have to understand the context of having a baby in a woman’s life. There’s a huge build-up. Everyone’s all excited. They’re having showers and parties. And imagine how difficult it is for women to admit they’re not so happy and they can’t take care of their baby. So, they often don’t come forward and talk about it. They feel shame instead of realising they have a medical condition that needs treatment. Also, I think we all know that women are socialised to take care of others and not themselves, and I think they have trouble coming forward and saying that they need help.
And finally, I think it’s hard because having a baby is so exhausting and so sleep-depriving that some women just think that’s the way that having a baby is supposed to go – that you remain exhausted, sleep-deprived, kind of depressed all the time. So, sometimes they have trouble discerning whether they’re in a depression or are just a normal postpartum person. And that’s why the clinicians are so important because it’s important to just have them report that to their clinician and talk to them about that.
00:15:33 Dr Jennifer L. Payne
Physicians are often reluctant to screen because they don’t know what to do if a woman is depressed, either during pregnancy or during the postpartum time period. So, there’s a lot of misinformation about whether we can use psychiatric medications during pregnancy and during lactation. And so, many doctors fear that if they screen they’re going to have to do something. In addition, there’s a real lack of mental health providers out there. There are long wait lists for people to get in to see psychiatrists – we do not have enough mental health providers at all. And so, if an OB-GYN screen and finds a positive case, they either need to treat or refer to someone else and there are problems with both of those choices.
00:16:28 Will Mountford
So, in terms of the treatments that are available if we could start with the more intangible aspects of the psychological treatments and social and community support, is there anything that can be prescribed in that, for example, kinds of therapy, but also the wider cloud of people around you and that social support?
00:16:44 Dr Jennifer L. Payne
Treatment of postpartum depression, for the most part, is not very different from the treatment of major depression outside of pregnancy or the postpartum time period. So, there are lots of different psychotherapies available, cognitive behavioural therapy, interpersonal therapy… all therapies can be helpful. I think the problem with therapies in the postpartum time period is that it’s very hard for young mothers with small children to find the time to go and do therapy once a week for an hour. That being said, we know that therapy can be very effective for postpartum depression.
In terms of medications, we use all different types of antidepressants, but selective serotonin reuptake inhibitors are thought to be particularly effective. In addition, there’s a new treatment for postpartum depression that was approved by the FDA in 2019. It’s actually an IV infusion over the course of three days: it’s a synthetic version of a hormone called allopregnanolone. And one of the neat things about it is that it works extremely rapidly, so women feel better within the first 24 hours. It has a very high response and remission rate, so something like 70% of women will respond to this treatment, and it appears to be effective even after the infusion is stopped. Now, the downside of that treatment is that you have to go into the hospital to be monitored in order to get that treatment, and it’s very expensive – but it can be really lifesaving in severe cases of postpartum depression. But really, almost any antidepressant can be used to treat postpartum depression, depending on a woman’s history.
00:18:37 Will Mountford
And you mentioned briefly the idea of any permeability, anything that might be passed on through the placenta during pregnancy and through breast milk afterwards. Is there anything to be wary of around those points?
00:18:49 Dr Jennifer L. Payne
Yes. So, there have been a ton of studies on whether antidepressants are safe to take during pregnancy and a little less studies for during lactation. I would say that antidepressants are probably the best-studied class of medications during pregnancy, and I think that’s because people thought that probably women should not be taking them during pregnancy. On average, they’re really considered to be relatively safe during pregnancy. In comparison, we know that when women stop antidepressants for pregnancy, 70% of them will relapse with their depressive disorder.
There are also a ton of studies looking at the safety of being depressed during pregnancy and postpartum. And what we know is that being depressed is not good for either the mother or the baby or the pregnancy outcomes. So, being depressed in pregnancy is associated with preterm birth, low birth weight, preeclampsia, and gestational diabetes; it’s also a risk factor for being depressed in the postpartum time period. And being depressed postpartum can have lasting effects on the baby’s IQ and language development. So, being depressed in that peripartum time period is not benign and is not something that a mother should just tolerate and get through.
Most antidepressants are really considered safe during pregnancy and lactation. There are a few exceptions. We prefer to use older medications that we know more about because they’ve been around longer. But in general, antidepressants can definitely be taken during pregnancy and during the postpartum time period, when a woman is breastfeeding.
00:20:34 Will Mountford
I suppose it’s one of those things where the harms of no treatment outweigh the harms of treatment. To come at it from another way, the sentiment of prevention being better than cure is one that I find applies across all kinds of medicine – could I ask for your thoughts and some of the wider conversations around that?
00:20:51 Dr Maureen Sayres Van Niel
Well, actually, it’s funny you asked about that because recently I have come to understand the importance of socio-economic determinants of putting pressure on a woman’s life, such that she’s more likely to develop these kinds of problems. And I think that I’m talking about women who are much more likely to get these conditions because they’re existing in a world of financial restrictions, no community support, perhaps single parenting, not getting good prenatal care. They’re experiencing racism or discrimination or a lack of housing. And what we see is that to some extent, if we can intervene with the conditions that some women are living under, we can do prevention in the same way we might approach it biologically as well.
00:21:46 Will Mountford
Is there anything that’s been going on in terms of pharmacological development, clinical trials for populations affected by the pandemic, say? That seems like a big one to consider.
00:21:56 Dr Jennifer L. Payne
So, I just completed a study in which I partnered with the mobile phone app Flo Health, which tracks women’s menstrual cycles – but can also track women’s pregnancies. And when a woman has had a child and she’s been tracking her pregnancy, it will send them a survey asking questions about their mood. So, I was able to partner with them on several different projects. But one of the interesting ones: we looked at rates of self-reported postpartum depression symptoms in women before the pandemic in the United States, and then we looked at rates in the first year of the pandemic. We saw a clear increase in reported postpartum depression symptoms during the COVID-19 pandemic. So, we know that the stress of the time clearly increased the rate of postpartum depression symptoms, at least in the United States.
00:23:01 Will Mountford
Are there any other ways in which detection is changing? We mentioned some of the screening protocols. Is there anything towards the start of disease onset or detection that could be done to shore up personal defences on a national healthcare system scale?
00:23:18 Dr Jennifer L. Payne
There’s certainly a lot more discussion these days about the importance of maternal mental health. So, there have been a number of legislative processes going through Congress, there’s now a national helpline that mothers or families can call and receive information on resources and help. But I think what it’s really going to take is making sure that particularly OB-GYNs, but also paediatricians, feel that they can screen and know what to do if a woman screens positive. And I think that’s going to take encouraging screening and increasing education to all physicians about how to do basic management of psychiatric disorders during pregnancy and during lactation.
00:24:12 Will Mountford
Could tell us more about some of the research that you are doing that we can look forward to finding out more about in the near future? Any upcoming papers or projects.
00:24:19 Dr Jennifer L. Payne
I mentioned the new drug, which is an IV infusion over the course of three days. It is a synthetic version of the hormone allopregnanolone, which is a neurosteroid that affects a certain receptor in the brain called the GABAa receptor. And so, some of my work is looking at levels of allopregnanolone and other neuroactive steroids prior to the onset of postpartum depression and seeing if we can detect any patterns that are predictive of who might be vulnerable to the development of postpartum depression. That’s what I’m really excited about right now.
00:25:00 Dr Maureen Sayres Van Niel
One of the things that I’ve been working on, which kind of comes at it from a different angle, is that the United States, as you know, is one of the few countries in the world that does not have a paid maternity leave or paternity leave policy, so that women can be relaxed and home with their children and having a good experience following the birth of their baby. There are so many women in this country who do not receive more than two weeks paid leave – they go back to work because they have to go to work in order to get paid. So, if they have a baby and they take three months unpaid, they cannot survive. Many women, we found only 25% of women, have a secure paid leave policy. That means for a number of weeks after the birth of the baby, women don’t have time to stay and take care of the child and have their partner also become a part of the situation because partners also are lacking this.
We did research on the mental and physical health effects on the baby and the woman of not having a paid leave in this country, and we found that there were a lot of consequences to physical but also prominently to mental health by not having a paid leave. We published that in the Harvard Review of Psychiatry recently. On the basis of that, I have been advocating on a national level for the United States to adopt a paid leave policy on a federal level. And we have worked in the various states as well. The states are having much more success. In Massachusetts, we have the most comprehensive paid maternity and paternity plan, including sick leave, that exists in the country.
00:26:52 Dr Jennifer L. Payne
Yep, Maureen has really done some pioneering work in this area. And it’s been really awesome to watch her go with this. I will say I did another study with the mobile phone app Flow, in which we looked at over a million pregnancies across 138 countries. What we found was that on a country level, countries that had paid leave and more economic opportunities for women had lower rates of postpartum depression symptoms. So, on an international scale, we know that paid leave should be a policy that nations should be instituting if they want to protect maternal mental health.
00:27:42 Will Mountford
If there’s anyone listening to this who is an expectant or a new mother, or a professional who deals with expectant mothers, think about any clinicians, or people working in support and care as well, is there anything that you’d like for them to take from this episode, to take from your research and bear in mind going forwards?
00:27:59 Dr Jennifer L. Payne
I would say postpartum depression and perinatal depression are real entities that need to be screened for and treated. They’re very treatable. And if we do a good job of screening and treating perinatal depression, we improve outcomes not just for mom, but for the entire family and the baby.
00:28:19 Dr Maureen Sayres Van Niel
Yes, and it’s important to tell everyone that the problems we’ve been discussing today, which can occur commonly in any woman who is pregnant or postpartum, can get better with treatment. The important thing is that calling for help is the first step you can take to make things better, not only for yourself but also for your baby.
There are 24-hour hotlines you can call at any time to be connected for help. In the US, there’s a national maternal mental health hotline that can be reached at any time at 1-833-943-5746. We have a new emergency mental health crisis hotline in the United States that just got started this summer, and this is to be used by people in any mental health crisis, including women who are pregnant or postpartum. And especially if they’re having any suicidal thoughts. The new three-digit number is 988, in the US. You can get immediate help at 988. The UK versions of these hotlines are to call 111 for emergency psychiatric support, that’s 111 or you can text (in all caps) ‘SHOUT’ to 85258 – that’s 85258. You can call these numbers now or at any time going forward for help.
As providers, we need to be attentive to the possible existence of this problem and screen for it. But as a mother, I think we need to be able to know that we are no less of a mother for experiencing something like this. We are women who are struggling with a medical condition, which was not very well understood through history, but is a discrete medical problem that needs treatment – and that treatment does exist.
And honestly, I’ve seen a lot of women get much better and look back at that time, as soon as they get the treatment, as just a short period in their lives that they came out of and enjoyed the experience with their baby after receiving treatment.
00:30:42 Will Mountford
Dr Van Niel, Dr Payne, thank you so much for your time today.
00:30:45 Dr Jennifer L. Payne
00:30:45 Dr Maureen Sayres Van Niel
Thank you, Will. Appreciate it.