 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through All CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation on postpartum depression. Over the course of the next hour or so, we're going to define postpartum depression and differentiate it from postpartum psychosis. We'll identify some risk factors for postpartum depression, identify screening tools and protocols that can and should be used in order to help early identify or identify early postpartum depression. We'll discuss the impact of postpartum depression on the mother, child, and family. Talk about some of the potential causes of postpartum depression and finally explore current biopsychosocial interventions for postpartum depression. So postpartum depression usually occurs in the first four to six weeks after giving birth and it is unlikely to get better by itself. And my son asked me an interesting question last night when we were talking about this. He's like, well, if postpartum depression is caused by hormones, then once the hormones stabilize, shouldn't the postpartum depression go away? And my answer was, well, you would think, but no. 50% of patients experience depression for more than a year after childbirth. So we need to look at what else is going on that's precipitating or maintaining postpartum depression besides just hormone changes. Women who are not receiving clinical treatment, 30% of them were still depressed up to three years after giving birth. So again, it can't just be hormones because hormones restabilize after birth. So what's going on here? When we talk about postpartum depression, it's kind of a broad term. Normally we think about the two weeks right after to four weeks right after time period. But it can start as early as 20 weeks gestation out to four weeks of age for the baby. Now, the other thing that I'll point out and whether you want to call it postpartum depression or hormone-induced depression or whatever you want to call it, many women also experience an upsurge of mood symptoms when they quit breastfeeding. So if the mother's breastfeeding for six months and then when she stops, mood symptoms may resurge. Now, whether that occurs only in women who had some sort of postpartum depression going into it or you can have somebody who's doing okay and then when they stop breastfeeding, the change in hormones as well as losing that bonding activity with the child precipitating postpartum depression, they're not really sure. But it is important to know and to educate women and to be aware of when we're working with women who have young children that they may have an upsurge in symptoms. The good thing is a lot of the time with the symptoms that occur when the mother stops breastfeeding, those do tend to remit after the hormones restabilize. So a couple of weeks and they're feeling better but there is an upswing in depressive symptoms and anxiety symptoms for some women. So back to traditional postpartum depression, the stuff that kicks in right before birth to four weeks after birth. According to the Centers for Disease Control and Prevention, up to 20% of new mothers experience symptoms of postpartum depression. This is more than just the baby blues. So one in five. That's important to know, one in five. Postpartum blues is a relatively common emotional disturbance with crying, confusion, mood-lability, anxiety, and depressed mood. These symptoms appear during the first week postpartum and last for a few hours to a few days and typically resolve on their own. You know, again, just like when you quit breastfeeding right after you have a baby, there is, you know, this rapid change in hormone levels which can make people much more emotional for a short period of time combined with the fact that, you know, in the first couple of weeks after birth, you're probably not sleeping much because the baby needs to be fed, you know, pretty often and is waking up a lot. At the other end of the spectrum, you know, we talked about baby blues. The other end of the spectrum is postpartum psychosis. Postpartum psychosis refers to a severe disorder beginning within four weeks postpartum with delusions, hallucinations, and gross impairment in functioning. Now, there are stories or whatever you want to say, accounts of women who have older children who have symptoms of postpartum psychosis. So whether we're going to say that that was postpartum depression that just never remitted because it went on for two, three years and then it got worse, that could happen. So we don't want to just assume that if we get through the first four weeks that there isn't ever going to be a chance of postpartum psychosis or psychosis. You need to be aware of it and just be cognizant. And whether you want to call it postpartum psychosis or major depressive disorder with psychotic features, you know, you'll work with the DSM-5 and the doctor and everything to define what it is. The point is, it's psychotic behavior. And with this psychotic behavior, there can be danger to the mother, to the infant, and potentially to the partner or the rest of the family. Postpartum depression is kind of right in the middle. It begins in or extends into the postpartum period and core features include dysphoric mood, fatigue, lack of appetite, sleep disturbances, anxiety, excessive guilt, and suicidal thoughts for at least a month. That's a long time to feel this way, especially when you have a new baby. And a lot of the guilt may come from not being able to feel like you can connect with your infant, feeling distant from your infant, questioning whether you're a good mother. So we want to look at what is prompting these guilt feelings and start addressing some of those cognitions in treatment. And it's important to remember that a lot of mothers, you know, 20% of mothers experience symptoms of postpartum depression. Less than 2% of them go on to develop postpartum psychosis. So it's, you know, if somebody has postpartum depression, we don't want to start getting them freaked out that, you know, they could become dangerous. So let's talk about psychosis for a second because people get freaked out about it and they assume that it's one and the same as postpartum depression and it is not. And I can't underscore that enough. Postpartum psychosis is a rare illness compared to the rates of postpartum depression or anxiety. It occurs in approximately one to two out of every thousand deliveries or one tenth of a percent of births. Okay, so the onset is usually sudden. Most often within the first weeks, first two weeks postpartum, not always. You don't want to, again, you don't want to just assume, well, we made it through the first two weeks. So we're not going to have any psychotic episodes. Not true. So do be aware. The symptoms that we're going to be looking for as clinicians, nurses, caregivers, delusions, or strange beliefs which are egocentonic, what does that mean? That means that the mother doesn't see anything wrong with them. She has strange beliefs maybe about her baby being possessed or the need to wash the baby in really hot water in order to get rid of the germs on it or something. And it makes total sense to her. And she doesn't understand why people are questioning her thought patterns and her behaviors. So egocentonic means it makes sense to that person and everybody else is going, yeah, not thinking that is really an accurate assessment of what's going on. The mother may have hallucinations, seeing or hearing things that aren't there or even feeling it. You can have tactile hallucinations where you feel like bugs are crawling on you or something, feeling very irritated, hyperactivity, a decreased need for or inability to sleep. You know, see some of this sounds just like depression, paranoia or suspiciousness, rapid mood swings, and difficulty communicating at times. Now, again, a lot of these symptoms sound like anxiety and depression, and we're looking at the quality or the intensity of the symptom and we're looking for those delusions and hallucinations. That'll really set apart the postpartum psychosis. The most significant risk factor for postpartum psychosis are a personal or family history of bipolar disorder. So that's an easy one. When we start seeing a woman or when a OBGYN starts seeing somebody, they need to screen from jump and pediatricians to from jump about whether there's a family history of bipolar disorder or whether the mother has had a previous psychotic episode, you know, depressive features with or depression with psychotic features or you know, some other sort of psychotic disorder. So if there's a family history of bipolar or if the mother has had a previous psychotic episode, she's definitely at higher risk for postpartum psychosis. As a side note, valproic acid, which, you know, depicote is the trade name or one of the trade names, has a high rate of causing multiple congenital abnormalities as do a couple other medications including lithium. Why do we care? We don't prescribe. Well, that's true. However, if we're seeing a mother or a woman and we find out that she's pregnant, you know, she says, oh, I just found out that I'm four weeks pregnant and we know that she's on psychotropic medication and she hasn't started to get prenatal care. We need to urge her to go see an OBGYN like ASAP because a lot of the medications can cause problems in the infant. So we need to advocate for the infant with the mother and say, you know what, it's important. I know you don't think that early prenatal care may help if that's the case, but we need to really motivate them to go to the doctor. So let's talk about scary thoughts for a second because we've talked about psychosis and remember psychotic features, the symptoms, the delusions are egocintonic. The mother thinks they make complete sense. They're not scary at all. It's just logical. A lot of mothers with postpartum depression have scary thoughts. Scary thoughts can come in the form of thoughts of what if I drop the baby? What if when I'm driving, you know, I'm going over a bridge and I just drive off the side of the bridge? Or they may have images like when they close their eyes, they may imagine the baby falling off the changing table or imagine stabbing their baby. Or there are a lot of really gruesome scary thoughts that mothers can have in the postpartum period. Scary thoughts happen, but it doesn't mean they're going to do them. They're not command hallucinations. They are not telling the mother to do it. And what they found in the research is the scary thoughts are really pretty common. We just don't talk about them, we being mothers, because we're afraid that if we talk about them, people will lock us up, think we're crazy, try to take our children away, etc. So we need to normalize this behavior because if mothers are having scary thoughts, it's going to often, especially if it involves working with their baby, you know, scary thoughts about doing harm to their child. They may not be able to bond with that child because they're too afraid to be around it. So we need to make sure that we address the scary thoughts. Now, sometimes the scary thoughts are so untenable that they need to see a counselor. And sometimes they even need to go on a short course of medication. I know I had really bad postpartum depression with my first child, and I had some really gruesome scary thoughts. And the doctor ended up prescribing a medication that I could take as needed, PRN, if the thoughts got too bad. So I wasn't afraid to be around my child. But it's important to start talking about this. I did a presentation at one of the hospitals where I used to live in Florida for a bunch of nurses. And I had two nurses start sharing when we were talking about this about the fact that, oh, I didn't know that was normal. These are labor and delivery nurses, and they had no idea that scary thoughts were normal. And they're like, yeah, I had those two, and I thought I was losing my mind. So it's so important that we educate parents. And in the class on all CEUs, I do have a worksheet or a list handout, whatever you want to call it, about scary thoughts. And I have some more references for you to work with parents. Now, does that mean we should just dismiss all scary thoughts? No. You know, the mother is going to need help so she doesn't distance herself from her family or her child. The mother will need help coping with those thoughts because it's natural to feel guilty and think, oh my gosh, I must be a horrible person if I'm imagining this. So we may need to help her work with that. But we also do want to keep an eye out to make sure that it doesn't start becoming egocintonic. We want to make sure those scary thoughts still prompt some anxiety because that is normal. Or at least the mom can say, you know, this is not normal. This is not me. I'm not going to do this. As she gets further away from the pregnancy and the hormones stabilize and everything else, the scary thoughts go away. And it's one of the things that you can do with moms is have them log their scary thoughts. If they don't want to write them down because they're just too horrible, you know, that's okay. But hash mark so they can start seeing their scary thoughts going down. So they're having to a day instead of to an hour. Scary thoughts can be indirect or passive. They may have indirect thoughts like something might happen to the baby if I leave it in its room and it's sleeping. Something the cat might crawl into the bed and get on top of the baby and suffocate it. Or the thoughts can imply intention, like I said, such as images of stabbing the child. And you hear that and if you have never had scary thoughts, you might be like, oh my gosh, you know, what would prompt that? They don't know what prompts these scary thoughts. The best hypothesis is that the neurochemicals are going a little bit wonky and the brain has thoughts and feelings and memories that it's trying to deal with. They don't know where it comes from. And that doesn't make a lot of moms feel happy because they're like, well, how can my brain even do this? We don't know, but we know it's common. Scary thoughts are not underscore, underscore, underscore are not an indication of psychosis. They can be part of postpartum obsessive-compulsive disorder or postpartum depression. So again, they're not a sign of psychosis, but we want to, you know, not just assume, well, there's no need to worry about those. There's a whole bunch of reasons we need to address those, including attachment, guilt issues on the mom. And it can, you know, keep her in a postpartum depressive state, you know, if she's having those feelings and feeling bad about herself as a mother. Scary thoughts will make the woman feel like she's a bad mother. They will make her feel guilty and ashamed. Reminder that it's a good sign if the thoughts are worrisome. And these thoughts are not about who she is or her capability of a mother. So we want to use that challenging questions worksheet that I refer to so often. And when she says, this must mean I'm a bad mother. Okay, so let's look for the facts for and against that statement. What are the facts that you're a bad mother? Aside from having these thoughts, you know, give me some evidence that you're a bad mom. Okay, give me some evidence that you're a good mom and really have her put that down on paper in black and white so she can see it. And she can see, you know what, I'm a good mom. My brain's doing something kind of funky right now, but I am a good mother and I love my child. Scary thoughts typically focus on the baby, but can also center on thoughts about the mother, you know, self harm to the mother or the partner. Scary thoughts can be intermittent or constant. So, you know, my personal experience was they were pretty darn constant. And it was terrifying whenever I was alone with my child, I was afraid to be alone with my child before, you know, I sought intervention. But they can also be intermittent where they may only occur at night or they seem to just come from out of the clear blue somewhere. They may be accompanied by compulsive behaviors such as checking, going in and regularly checking that the baby's still alive. And you didn't let the cat in the room to lay on its head or what have you. Some examples of scary thoughts. I'm afraid I might take one of the knives in the kitchen and stab my baby. I know we've talked about that on three slides now, but that was one that kept coming up when I was doing this research. I can picture myself driving off the road with my baby in the car. I think my family would be better off without me. I'm having sexual thoughts about my baby. I can see terrible graphic violent things happening to my baby. And, you know, depending on your approach, you may or may not have the mother describe what these violent things are. But in reality, that's not really all that important. You know, how she's hurting the baby is not as important as the fact that she's imagining or she's seeing that something awful is happening to her baby. So helping her develop a sense of safety, a sense of, okay, what do I do when I'm starting to have these thoughts that are ego-distanic? They're not part of who I am. They make me concerned. When you start having these, what can you do? Distract is one of the things. If you sit with it, if you have that thought and then you start sitting and becoming afraid of acting on that thought and starting to wonder what's going to happen, it ramps things up. So encourage moms when they're having these thoughts, you know, they need to do something. Number one, get in a place where they feel safe. Number two, and sometimes they can't leave. You know, sometimes it's not practical to go to a neighbor's house. But they might be able to call a friend and talk to a friend because while they're talking to the friend, they're distracted a little bit and they know, sort of, that they're safer. They're not likely to do something graphic or violent while they're on the phone with their friend. So encourage them to make a list of things they can do when they start having these thoughts that can help them distract, feel safe and get past it. Encourage clients to focus on the thoughts that empower them. They need to practice radical acceptance. Instead of thinking, when they have that thought, instead of going, I shouldn't have this thought and this is an awful thought and I must be an awful person. Just, I'm having this thought. It's not part of who I am. I'm having the thought that I'm going to hurt my baby. I'm going to have, I'm having the thought that something awful is going to happen to my baby. It's a thought. It will come and it will go. So accepting, you had the thought, okay, well, let it go. You know, don't judge it. Don't label it. Don't shoot it. Just let it go. And that is hard. I'm not saying it's easy, but letting it go and part of letting it go or one way to help mothers let it go is to help them understand that it's common. It doesn't happen or we don't know exactly why it happens, but it happens for a lot of women and it doesn't mean that they're a bad mother. So they're having this weird thought. Let it go. Just like, you know, before they were pregnant or before they had a baby, they probably had nightmares about different things. You know, even when they were kids, did they enact their nightmares? You know, no, they didn't. So this is just their brain playing tricks on them. Encourage them to practice mindfulness exercises. This can help them get out of that emotional mind and it can be as simple as looking out the window and identifying 10 things they see or turning, you know, finding something in the house and looking at it and identifying as many characteristics of it as they can. They can do four, three, two, one, four things they see, three things they hear, two things they smell, and one thing they can feel. Whatever mindfulness exercise works for them, they can even get a cup of coffee or something they like to drink and focus on mindfully drinking that. What does it taste like? What's the temperature like? What does it feel like when they swallow and it goes down their esophagus? Anything to get their focus on something besides that scary thought. And encourage them to remind themselves that they're not always going to feel this way. It does go away. If there are other mothers that you've worked with who've had scary thoughts that are willing to be support people, you know, that's always helpful. Obviously, that's, you know, a HIPAA thing, you know, they have to be willing to volunteer to reach out to other mothers. But if you can get those releases signed, it can be really helpful for a mother who's experiencing it to talk to one who's been through it and everything came out okay. Encourage the woman to tell someone she trusts how she's feeling and let them reassure her that she's going to be okay when she gets the treatment she needs and that she's loved and safe. You know, sometimes this resolves on its own, but a lot of times when women start having the scary thoughts and postpartum depression, they at least need some sort of counseling intervention, whether that's with a nurse practitioner, a counselor or a psychiatrist or somebody. They may not need medication, but they may. You know, it just depends on the woman and how frequent and intense these thoughts are. If she feels that her thoughts are out of control or she cannot manage the intrusion, make a referral to a perinatal specialist. So we really want to look at counselors who aren't going to get freaked out by the scary thoughts thing. They understand it's a normal thing that happens in some women who have postpartum depression or a common thing, if you will. So we want to refer to somebody who is not going to stigmatize them even more. And this can be a perinatal specialist, a psychiatrist. If it's bad enough, they can call 911. You know, it depends on where the mother is at. If she's really, you know, terrified, she may need to do whatever she needs to do to stay safe. If the woman's thoughts are worrisome to you, but she feels like her thoughts make sense and everybody else is crazy. It's an emergency and she needs to be evaluated by a psychiatrist or physician immediately because we've crossed over into postpartum psychosis. For like the tenth time, postpartum depression rarely progresses to postpartum psychosis. Scary thoughts are a common part of postpartum depression and don't mean the person the woman is going to progress to postpartum psychosis. You know, there's not a direct correlation there at all. Women who have experienced postpartum depression have a 50% to 62% risk for future depressions, not just postpartum depression. Be aware of that and let them be aware of that. So if they start feeling blue, they can reach out for early intervention before they get into a full blown major depressive episode. If they've had postpartum depression before and they get pregnant again, there's a good chance that they're going to get postpartum depression again. So they can work with their OBGYN who can help them a lot of times, not always, but there are a lot of OBGYNs that will get the mother started on antidepressants, SSRIs, in the third trimester, because there's what we'll talk about medication in a little while, but there's very little risk to the fetus in the third trimester according to the studies for certain medications. So a lot of times the OB will weigh the difference or the way the risks of having a mom with postpartum depression who can't bond with her baby versus starting mom on antidepressants in the third trimester. So that's going to be between mom and the OBGYN. So other risk factors for postpartum depression, if this is a first baby and they don't know if they're going to get it or not, if they have a history of mood disorders or premenstrual dysphoric disorder. If they have depressive symptoms during their pregnancy, maybe it doesn't meet the threshold of major depression or even persistent depressive disorder, but they've got some significant depressive symptoms. It's important to know. A family history of psychiatric disorders, stress factors such as negative life events. If mom's pregnant and she finds out that the baby has some sort of birth defect or she has a premature delivery or she and the spouse or the baby's daddy split up, whatever the case may be. Any kind of psychosocial stressors can contribute to the development of postpartum depression. Lack of support or a poor marital relationship can lead to it. Having a special needs or medically fragile infant, which again is one that may have birth defects or is premature. If the mom has a history of substance abuse, eating disorders or other family dysfunction. So when we look at these factors, you know, a lot of them are really common for run of the mill, if you will, persistent depressive disorder or major depression. But you add on top of that new hormones and new baby, not sleeping, all the vulnerabilities that come with that, although they're well worth it because little kids are awesome. You can see where mom could be at greater risk. So it's important that mom is able to minimize as much stress as possible and avoid as many negative life events as possible. That she has good support, whether she's a single mom or she's married or whatever the case may be. It doesn't matter who the support is, she just needs support. Paying attention to any depressive symptoms during pregnancy and educating mom about vulnerabilities, why nutrition is important, why sleep is important. And helping her develop a plan so she knows how she's going to get enough sleep and eat a decent diet after baby is born. You know, those first few weeks, sometimes you're really lucky to get a shower. So you're thinking how in the world am I going to make a meal that's, you know, three meals a day that are well balanced. Well, let's figure out how to do that. How can you get support to help you do that? How can you make that happen? And how can you get enough sleep? So important. Other factors that are prominent. Now postpartum depression, and this may surprise you, isn't just a mom thing. Postpartum depression can also impact partners. So changing roles and responsibilities, you know, going from being a husband to being a father as well as a husband and having to be responsible for this new life in the world can be really intense for a lot of dads. They may feel excluded when attention is on the new baby. They may miss the sexual relationship and feel overwhelmed at the financial and care obligations. Not to say that mom doesn't have all of these, but these factors are really prominent and things that we want to look for risk factors for depression in the partner during the postpartum period. Other children may also feel abandoned, jealous and resentful of the new baby, which can add additional stress or guilt to parents. You know, when a new baby comes in, the kids place in the family is changed. Suddenly they're responsible for helping out a little bit more. Sometimes they're going to get less attention than they had before. Doesn't mean they're not going to get enough attention, but they may not be the sole focus of attention. So it's important to look at how does bringing this new person into the family system upset the apple cart because then you're going to have to rebalance it. And during the pregnancy period, it's important to try to ease this transition and figure out how you're going to make sure that other children feel like they're still important and don't feel put upon and deal with any jealousy. Or resentment that may come up. Okay, so the impact of postpartum depression does not just stop when when the infant gets older. Postpartum depression impacts can carry on for a lifetime. Yeah, they've done studies, it can carry on for a lifetime. Why is that? Because postpartum depression can disrupt that primary attachment relationship. And if you think about Erickson, during that initial period, it's trust versus mistrust. And if they're not able to bond and form that safe secure home base, they don't learn to trust. We're going to look at why that might be in a couple of seconds. So inadequate prenatal care, poor nutrition, higher preterm births, low birth weight, preeclampsia and spontaneous abortion are all common in women who are depressed going into before they even have the baby while they're pregnant. If a woman starts getting depressed, you can have any of these things. Inadequate prenatal care, you know, that can have its own risk factors. Poor nutrition can keep the baby from developing as well as it should. Preterm birth, you know, if the baby comes out before it's supposed to, that means it's not finished developing. So there's a whole host of things that can go wrong with the baby. Now, that's not all doom and gloom. You know, I had two premies. I know dozens of parents who've had very premature infants and the children are just fine. But a preterm birth does get the baby off to a rough start. Because of poor nutrition and high stress levels in mothers who are really depressed when they're pregnant, the baby can have low birth weight. And potentially, the mother's body can spontaneously abort the infant. If there's enough stress going on, it disrupts the sex hormones. And you know you've got to maintain certain levels of estrogen and progesterone in order to stay pregnant. So it can switch and trigger a spontaneous abortion. Minimizing stress and really addressing depression in the prenatal period to make sure baby has the best developmental start to life. During the infancy period, if mom has postpartum depression, the babies may show symptoms of anger and distancing, averting their gaze from mom because there's just too much tension. It's not this loving look between them. It's mom looking at the baby going, I just can't even deal with you. So the baby may distance or avert their gaze because it's too overwhelming to look at mom. They may be passive or withdrawn where they just don't make much sound at all. They often have poor self-regulatory behavior. They cry a lot. Or and or they may have dysregulated attention and arousal or responsiveness. So they may be really, really focused or they may not focus on anything at all. You know you try to play with them and they're just not even noticing. Or and or they may startle even easier than your average infant. Cognitively, they've shown that when you use the Bailey scales, infants of mothers with postpartum depression show lower cognitive performance. Socially, mothers with postpartum depression exhibit fewer instances of maternal child touch and positive engagement activities such as reading books, singing songs and playing games. It is so important that the child not go from crib to swing to high chair back to crib again. Children need to be held and played with and touched and you know interacted with. So they develop that sense that parents are there for them and they can develop that attachment relationship. Mothers with postpartum depression display less sensitive behaviors towards their children. Now when we say sensitive that means they're not as accurate as identifying and identifying when the baby is hungry, sleepy, cold, wet, whatever. It's generally okay just shut up. I'm going to pop something in your mouth whether it's a binky or a bottle. They tend to respond to their children's needs in less responsive, attentive and nurturing manners. So instead of picking the baby up and going okay let's either let's nurse or let's eat and I'm going to hold you and rock you. They prop the baby up on something and prop the pillow, put a pillow under the bottle and just kind of set them there to eat. So it's important to look at those interactions and a lot of parent infant psychotherapy involves looking at these early interactions and trying to help moms see where they can do things that will improve that attachment relationship. These withdrawn behaviors on the moms part just not being able to engage and hold and nurture their child inhibit the formation of a caring, attentive primary attachment. The attachment relationship also suffers from a lack of physical touch which is crucial to the development of children's regulatory skills and ability to cope with stress. One of the things we notice in parents with postpartum mothers with postpartum depression but I guess I can say parents because it's true. When the parent that's holding the infant is stressed out, the stress is palpable to the infant so the infant will get stressed out. My son had reflux and kind of played out. I knew this but he just kind of demonstrated it for me when he was younger. We would have to walk him and rock him and you know do whatever we could because when he would lay down he would regurgitate and it would hurt and he would scream and it was awful. But then sometimes he would just cry because he had a bellyache and a lot. So I would hold him and I would rock him but when I would start feeling myself getting stressed out I would hand him off to his dad and his dad would walk him and we noticed that if we continued to hold him when we were stressed out not only did he get more stressed out but you could look at the nonverbal behaviors and see the stress emanating from whichever parent it was because the rocking became a little bit more aggressive for example or became non-existent or the person would tense up. There are a lot of different nonverbals you can see that communicate a distancing even if you're still holding the infant. So it's important that children have positive physical touch and that touch helps them learn how to regulate. So when they're touched, when they're picked up by mom they know that it's safe and it's secure and it's calming. Not, oh my gosh this is going to be even scarier. As a toddler if mom had postpartum depression you can see passive non-compliance and this is more true, it can be true if mom had really bad postpartum depression but it's better now because that primary attachment relationship never developed so you're going to continue to have problems. But it's also even more true if you've got a mother who had unaddressed postpartum depression who is still having depressive symptoms into the child's toddlerhood. Behaviorally the child may be passively non-compliant, you know mom says do this child looks at her like yeah whatever make me. But mom, when mom's depressed or parents are depressed if we're talking about both parents potentially having postpartum depressive type issues they may not correct the child. So the child does whatever they want despite what mom or dad tells them to do. The toddler may have less mature expression of autonomy. They may internalize problems and be very stoic or they may externalize problems and be the child that bites and hits and kicks when they get upset because they can't self-regulate. They may also have lower interaction with peers because when they interact with peers it ends up being something unpleasant. Cognitively they often show less creative play and problem-solving and continue to show less lower cognitive performance. The school-aged child, now we're talking elementary school now. We have impaired adaptive functioning because the child still hasn't learned that whole home-based thing. Think of Erickson's levels, trust versus mistrust, autonomy versus shame and doubt. We're starting to move in to these other places but the child has not developed a strong sense of autonomy because they didn't have a safe home base. They didn't have that nurturing relationship. They never learned to trust themselves and they also didn't learn how to self-regulate. So now that they're going to school and interacting with other children and having to adapt to different situations, that adaptive functioning impairment becomes much more obvious. They may continue to either internalize or externalize problems. They may have effective disorders. They may start even at this young age having depression or anxiety or conduct disorders. Academically you may start to see attention deficit hyperactivity symptoms and lower IQ scores. So why did I go through that? Mainly to help you see that there is a long process or list of problems that goes well after infancy if moms have unaddressed postpartum depression. That early attachment relationship that helps the child learn to feel safe, identify internal cues and self-regulate are so important for the rest of their life. So what do we do? All women should be screened even if it's not a first pregnancy. So people can have one, two, three kids and not have a problem but on child number four, all of a sudden they develop postpartum depression after that child. So we don't want to assume that if they've had a pregnancy before they're not without postpartum depression that they're not going to have a problem now. Screen, it takes like two minutes and it could really help the child for the rest of their life. New fathers should be screened as well. And I keep talking about moms but it's really parent that we want to look at for postpartum depression. The Edinburgh Postnatal Depression Scale is one that is really easy to use and let me pull it up really quick right here. Okay, so it has ten questions to it. That's all there is to the Edinburgh Scale. Ten questions and they're basically Likert answers as much as I always could, not quite definitely and not at all. So it doesn't take long to administer but it shows a great amount of validity and reliability in terms of identifying postpartum depression. Maternal mood in the immediate postpartum period or up to two weeks postpartum is a significant predictor of postpartum depression. Now it can get a little bit wonky if mom had a premature infant or if the baby was in the NICU because when the child is in the NICU the parents may be getting more sleep and then stress rapidly increases when the baby comes home. But there are a lot of different things that can happen. So we don't want to just say two weeks postpartum necessarily. I usually say two weeks after the baby comes home in order to give us a wider birth, so to speak, of when the mood issues may kick in. A lot of times when moms or parents have children in the NICU, they have a lot of support. They have the support of the NICU staff. A lot of times family are available then because the baby's in the hospital but then as soon as the baby comes home there's no NICU nurses, no therapists, no family support anymore and mom and dad are just going, oh my gosh, can I do this? So two weeks after baby comes home 73% of women who met criteria for postpartum depression screened in one study denied feeling sad. Wow. And they hypothesized the reason for this is that they were embarrassed or they feared being judged or they didn't have enough education about the negative impact of postpartum depression on the child. Sometimes other people can inadvertently make it worse by saying, oh, it's just the baby blues. It'll go away. And then, you know, it just drags on and on. So it's really important for us as providers, whether you're a social worker, a clinician, a pediatrician to regularly screen for postpartum depression and to normalize feeling, how feelings, how the parents are feeling. And to help them see that, you know, one out of every five moms experiences postpartum depression. It's nothing to be ashamed of. We're not going to judge you. We're not going to try to take away your baby. Causes of postpartum depression, they hypothesize. Hormone changes after birth and when stopping nursing. You have those hormone fluctuations. Lack of sleep. Pre-existing anxiety or depression issues, which tend to be made worse by lack of sleep and hormones. History of abuse or neglect is a young child. Now, this is one where a PTSD sort of situation may be triggered when, you know, mom hadn't dealt with the abuse or neglect or maybe she had, but then when she has the baby or both parents for, when the new baby comes home, both parents or the parent who was abused starts thinking back about, oh my gosh, you know, this is what my childhood was like and all those memories come flooding back. So it's important to be aware that abuse or neglect as a young child in one of the parents can predispose them to postpartum depression. Either parent, you know, you want to look at that. What does that child remind them of? What does that child represent to them? Maternal chronic illness, including lupus, fibromyalgia, diabetes, Lyme disease, chronic fatigue syndrome, polycystic ovarian syndrome, all of these can contribute to the development of postpartum depression. They're not sure how, but we're looking, since we don't know what causes it, what they do is called correlational studies and they say, well, it appears that it's more likely that a mom who has one of these things is more likely to develop postpartum depression. We can't say that it causes it. For certain, but these are strong correlations. Poor control of diabetes can also cause symptoms that look like depression in that postpartum period and during pregnancy. Sometimes it's hard to control diabetes. So these symptoms can look like depression, so we need to make sure that we're screening mom for diabetes issues as well as thyroid issues. If she's having depressive symptoms in order to make sure we're attending to the whole biopsychosocial situation. If she's developing hypothyroid, then she may need to go on medication. If she's developing adult diabetes, then she may need to start controlling for that and just those things may help her mood improve. Other things that can trigger cause or are strongly correlated to postpartum depression, miscarriage and stillbirth. That's a tough one. It doesn't matter whether the miscarriage was at 12 weeks or was it 32 weeks. It can be really devastating to the mother to lose a child. If she has to go through the whole labor and delivery process or if she was far enough along that she was showing and everybody knew about it, then it can be really impactful for a whole variety of other reasons. But I don't want to minimize the impact of losing a baby in the first trimester. Prematurity is traumatic. No matter who you are, if a baby comes early and you know that it's at risk for health problems and it's very, very fragile, it can be traumatic for the whole family. Birth defects can cause trauma or grief. Having a C-section. Some moms imagine their birth process going a certain way and then when it doesn't go that way they feel like they failed in some way. And lactation difficulties. Again, this is one that we're supposed to be able to easily do. It's supposed to be natural. And if your baby can't or won't nurse for some reason, the woman may feel like less of a woman or a bad mother. So it's important to, if she wants to try to breastfeed it's important to hook her up with a lactation consultant. They have a bunch of tricks. But sometimes, especially in premies and children with any sort of oral malformations may not be able to nurse. So it's important for moms to understand that. And lack of social support or intrusive social support. So we can understand the lack. If moms there trying to do everything all by herself and like I said, feels like she's lucky to even get a shower a couple times a week. Then you can start seeing circadian rhythms getting out of whack and mom feeling excessively stressed and becoming much more at risk for postpartum depression. Intrusive social support is when well-meaning family members come and start telling mom how to raise baby. Or criticizing or correcting or whatever they're doing regarding how parents are parenting the baby. So prevention and early intervention. For clients who are at risk work with the woman and family during the pregnancy to optimize mental health for all. We want to prevent postpartum depression in the partner as well as in mom. We want to make sure that the kids are adjusting and they're not resentful and angry and acting out. Increase personal awareness of stress levels and effectiveness at dealing with stress. Ideally for the whole family. And one of the things that I really like doing about family based prevention is you can give them activities to do. You can teach mom and dad or the parent parental units how to do a particular activity and then they can take that home and teach it to the rest of the family and then they can do it at dinner time each night or they can pick a time when they can do this activity. So it increases communication it makes sure that the parents actually know how to implement the activity because they're teaching it they're not only doing it but they're teaching it and it makes sure that everybody in the family is developing effective stress management skills. Prepare encourage the family to prepare for the new addition you know plan for what it's going to be like if mom is going to take maternity leave what is that going to look like what is she going to do during that period who's going to help her out if she goes back to work you know what is that going to look like who's going to help her out is the baby going to be in childcare who's the pediatrician make sure you have a car seat and a place for the baby to sleep and yada yada yada address any other concerns that parents may have you know if they've been a parent before they probably have a lot of their questions answered if they haven't they may have a whole slew of questions if they've been a parent before but this baby is incredibly fragile for some reason they may have a whole host of questions so let's start addressing those develop a postpartum plan so I encourage parents to figure out who's going to be in charge of baby when in order to make sure that mom can have a break periodically and get some sleep and you know it worked out really well for us because when my son was an infant my husband was on midnight shift so I was able to pump and during on the days that he was home overnight you know he stayed up overnight on his days off on the days that he was home he could take the middle of the night feeding so I could get a good solid six or eight hours of sleep and then that let me rest and recharge a little bit until we got through the period and the baby was sleeping through the night whatever parents need to do encourage breastfeeding or a combination of breastfeeding and pumping for late night bottle feeding not every mom wants to breastfeed and that's okay breastfeeding does help with bonding and attachment but if mom doesn't want to do that for some reason encouraging her to at least hold the baby when she's feeding is going to be important to that touch factor and establishing the attachment relationship weekly interactions and check in with a counselor to identify mental health and self-care needs of both parents are important so and if the person is at risk for ppd you're going to do weekly interactions and check-ins unfortunately the way our system set up that's not going to happen for every single parent if you can encourage them to do personal check-ins at least once a week to identify what's going on with them that is really helpful and then if they feel like they're getting depressed they can do something about it it doesn't go on for weeks and weeks and weeks but it is you know some places do have the ability to have a counselor that's based at the hospital or whatever check in with mom once a week just to say how are things going another acronym that you might think about is Nests S nutrition is important we need to help the body recover I mean that was a pretty traumatic experience to expel a baby mom's body needs to recover she's also potentially making breast milk which means she has additional nutritional requirements exercise is important get the serotonin out there release endorphins help get some of the pain and aches gone helps set that circadian rhythm good sleep is vital having time for yourself and we love our little munchkins but it's nice and I remember periods when my children were little just thinking to myself I would love to be able to just go to the bathroom by myself that would be so awesome time for self is really important and time with adults that speak in full sentences is really important again you may love your children I hope you do but it's really important to encourage parents to engage with other people their own age regularly so they don't feel like they're getting lost and get support the final S stands for support you need emotional support you need parenting support you know I remember one time my son was crawling and he was crawling after our dog and I probably shouldn't share this but I do and our dog was upset about having a new baby in the house and obviously was crawling so this is he should have gotten used to it but he hadn't and he was particularly upset that day so the dog was following me and pooping as he followed me and the baby was following the dog and eating the poop and I turned around and I saw him do this and I like lost my stuffing I was like oh my gosh so I called one of my friends who's a nurse and I'm like is he gonna die what do I need to do do I need to call poison control and she just kinda laughed she's like call the pediatrician if you're that worried about it but they'll probably be fine and so I mean it was parenting support I'm like what do I do with that you can't google what to do when your child eats dog crap it's just not there so there are times you need another parent there are times you need another parent to say okay your baby has colic have you tried this respite care respite support that means time away is really important so you know you'll love your kid and you want to spend time with them but it's also important to have time where you can you know just be with yourself for a second and get re-grounded adult interaction and peer support are also important other interventions for postpartum depression pharmacotherapy antidepressants are the first line and there are some that are better than others or electroconvulsive therapy can be helpful and electroconvulsive therapy is usually used for reserved for moms who either don't want to take medication or who are not tolerant of the medication for some reason psychoeducation about the causes and impact of postpartum depression the importance of self care treatment options techniques to address scary or unhelpful thoughts radical acceptance and mindfulness a lot of the psychoeducation can be done via video and the mom can log into your website and watch those videos you know at 2 o'clock in the morning while she's breastfeeding or something because a lot of times she's not going to feel like she's got the energy to go out and you know get dressed and go to an appointment and yada yada yada so if you want to increase compliance making these this information really available is important and then you know if you feel like you need to process the information with her you can either do a phone or a video chat or a home visit or whatever or maybe time it if you work out of a pediatrician's office time it where she comes and sees you the counselor right after she sees the pediatrician cognitive behavioral therapy has been shown to be very effective for postpartum depression for both parents and bright light therapy can help reset those circadian rhythms because again you know during that first couple of months before babies sleep them through the night your circadian rhythms get all out of whack you're not getting well at 8 hours of sleep so bright light therapy has been shown to be very effective at helping to improve low mood parent infant psychotherapy works directly with the parent and infant for about 16 weeks to observe the parent child interaction and this can either be direct observation that gets really expensive or through video so the parents record you know they have cameras up in their house and it gets recorded and then the therapist can review those review those tapes and initially you review a lot you know most of the tapes and then also ask the parent you know where are some periods you know can you tell me some times that you want to look at where you felt like you weren't as effective as you wanted to be or you were having problems getting the baby to calm down or whatever the case is and then you can go look at those specific areas but once you've watched enough hours then you start to get a general feel for the rhythm of the particular family and you can start sort of fast forwarding so you're seeing what's going on but you're fast forwarding until there are you know particular places that you want to stop and watch from beginning to end like maybe when mom or dad goes to try to put the baby down for sleep if they're having difficulty getting the baby to sleep in its own bed or whatever but because you have this video it helps to identify concerns and worries on you know that the parents are going through and we can figure out okay you're having this concern that your child is not willing to sleep in the crib okay so let's look at what's going on two hours before that up to and through trying to put the baby down what's going on it identifies patterns of relating and behaving so you know in that early period when you're watching you can see how mom interacts with or whoever's staying home with the baby interacts with the baby throughout the day is the baby always in a swing watching television is the baby regularly down on the floor and getting played with by somebody what's happening how much touch is going on how much positive interaction is going on versus how much just independent you know go over there and you know if you cry I'll come to you interaction is going on it helps us support the parent to develop different ways to relate to their infant if they're having difficulty bonding it identifies influences from the past they're impeding the parent infant relationship so you can look at it and you can kind of say you know what is this what does this remind you of or you know why does this cause you stress or when you respond to the child in this particular way where did you learn that from and what are you hoping the outcome will be emphasis is placed on the parents internal working models or representations of the infant in context of their own caregiving history and attachment experiences because we learn how to parent by the way we were parented so if they had ineffective parents growing up they're probably not going to have a wealth of effective parenting tools at their disposal so they're likely going to react in many ways similar to the ways their parent reacted to them so we want to help them see that and then they can make the decision about whether they want to continue reacting in that way or try to react in a different way the aims of parent infant psychotherapy are to learn to identify and meet the immediate presenting problems in the baby so figure out what all those different cries mean educate the parent about the relationship and the development of healthy attachment so we keep talking about attachment what is that what does that mean why is it important you know how does it help self-regulate so learning attachment theory in brief to parents is really helpful and help the parent and child feel more positively about themselves and their interaction so you want the child to greet the parent with a smile when they get to the point they can smile you want that secure attachment developed so we want to look at how to help parents develop that the effects of parent infant psychotherapy in the research have been increased self-esteem in both the parent and the child improved parent child interactions that are enduring reduced parental stress and reduced parent infant conflict so there's a reduction in the frequency with which parents get frustrated with baby because baby's crying all the time or baby won't stop touching things they're not supposed to or whatever it is so we'll touch briefly on infanticide because it comes up when we talk about postpartum psychosis many women who commit infanticide have no diagnosable mental illness that precludes them from being aware of the wrongfulness of their actions the exception is postpartum psychosis so many women who commit infanticide aren't in a postpartum psychotic episode they are perfectly aware of right and wrong and they choose to do it anyway for whatever reason so things that we need to do to screen for risk of infanticide have you felt irritated by your baby well we all occasionally do you know it's just one of those things if the baby goes through a particular particularly rough week where they're waking up every two hours or something because they're going through a growth spurt you can wake up and get a little irritated and be like child just sleep that's normal irritation what we're talking about is particular irritation where you start thinking I regret ever having this baby does the baby feel like it isn't yours at times you know that indicates a lack of attachment have you wanted to shake or slap your baby have you ever harmed your baby do you think the baby or you would be better off if the baby was dead do you have thoughts of hurting your baby if the answer is yes to any of these we want to proceed with a standard suicidal homicidal assessment looking at the plan frequency and thoughts of hurting the infant if that comes out and what has prevented them from slapping the baby or hurting the baby until now and start making a plan but it also indicates the need for an immediate referral of a medical professional medications the exposure of infants to relatively low doses of antidepressants through breast milk must be juxtaposed with that of untreated maternal postpartum depression which has well established negative consequences the benefits of breastfeeding for the mother and the infant's health is well documented so if mom is willing to breastfeed like I said earlier a lot of times OBGYNs will be okay putting mom on certain antidepressants because the research has shown that there's a really low likelihood of any problems sertraline which is zoloft or peroxidine which is paxil and nortriptyline and emipramine among the tricyclic antidepressants are the most evidence based medications in breastfeeding because of similar findings of undetectable infant serum levels and no reports of short-term adverse events so those medications have been well studied I mean they're your older generation medications so they've been around for a while, there's been plenty of opportunity for bad things to happen and they haven't so those medications are generally thought of by most practitioners as safe for mothers who are breastfeeding infants exposed to fluoxetine which is prozac had higher medication levels especially if exposed prenatally so some OB's will not prescribe that particular medication citalopram may also lead to elevated levels in some infants but more data is needed now citalopram is one of our newer antidepressants so the take-home from all this is there are some older generation medications that have been shown to be very very safe for use in mothers who are breastfeeding and the risk to the infant having mom on an antidepressant while she's breastfeeding appears to be much much less than the risks to the infant if mom doesn't have the medication and ends up developing postpartum depression the final thing I want to touch on and there's going to be a whole other class on this in the near future but opiates in pregnancy a lot of people think well if mom is on methadone or addicted to opiates when she is when she gets pregnant she needs to stop that's bad for the baby well it's not great for the baby no doubt but sudden opioid withdrawal for unborn babies can cause respiratory depression which can lead to the fetus not getting enough oxygen and maybe fatal so it can cause a miscarriage neonatal abstinence syndrome refers to the period of withdrawal experienced by many newborn babies that are born to opiate addicted women is it pleasant no you know it's awful to watch however the baby is alive and so when I was working at the methadone clinic our psychiatrist was adamantly opposed for these reasons of to discontinue methadone or opiates or he would switch the mothers over to methadone if they were addicted to opiates so he could monitor it but while they were pregnant they were still going to take methadone and as soon as they gave birth he would titrate them off the methadone levels of buprenorphine and methadone are low in breast milk and breast feeding should be encouraged so you know according to the current guidelines it's okay to breast feed if a mother is on methadone or buprenorphine now trexone effects are not as well known what are these things? suboxone which a lot of people are familiar with is a combination of buprenorphine and naltrexone and when you take that then suboxone keeps people from experiencing withdrawal effects so much naltrexone is an opiate agonist naltrexone is the antagonist so naltrexone keeps people from getting the high or from abusing the suboxone but since they don't know the effects of that the guidelines currently really indicate that moms should either be on buprenorphine or methadone or nothing at all postpartum depression effects about 20% of women and partners should be screened for depressive symptoms well postpartum depression can begin anytime between 20 weeks gestation and 4 weeks postpartum untreated it can last for years scary thoughts are often a part of ppd and should be normalized with parents not just with mom who is having them but with the moms partner so moms partner can provide support postpartum psychosis is egosyntonic and will not produce scary thoughts when mom has those delusions she thinks they're perfectly normal so you need to be really aware if mom starts having odd beliefs postpartum prevention involves nests s for both parents nutrition exercise sleep time for yourself and support treatment involves psychoeducation cognitive behavioral and or parent therapy certain ssri's antidepressants and tricyclic antidepressants have been found to be safe when breastfeeding it's important to remember that there are many triggers or correlations for ppd we don't know exactly what causes it but we know that people with these triggers are at a much higher risk for the development of ppd and that can include stress and a family history of or a personal history of mental health issues remember that one of the greatest predictors of postpartum psychosis is if there's a family history of bipolar disorder or if the mother has had a previous psychotic episode women at risk for postpartum depression should engage in early intervention and planning while still pregnant to ease that transition and make it and prevent as much of the problem as possible when baby comes home from the hospital if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with Dr. Snipes by subscribing at allceuse.com slash counselor toolbox this episode has been brought to you in part by allceuse.com providing 24-7 multimedia continuing education and pre-certification training to counselors, therapists and nurses since 2006 use coupon code counselor toolbox to get a 20% discount off your order this month