Postpartum Depression is Preventable
The newest and most rapidly rising cause of maternal mortality is behavioral health which comprises suicide, homicide and drug overdose, either accidental or planned. In some ways that gap between obstetricians and psychologists treating depression is a healthcare turf war. If obstetricians get too involved with treatment of obstetrical patients for depression, they will be criticized as practicing outside their field of expertise.
On the other hand, if I detected signs of postpartum depression in my patitents, it could take several months to get a referred patient in to see some kind of behavioral health practitioner, whether it’s a psychologist or a psychiatrist. I have also run across psychiatrists who claim they’re not trained to treat obstetrical patients, especially those with postpartum issues-—which is true. If the patient is visiting the obstetrician, they will hear that the obstetrician is not trained in treating psychiatric issues.
In a recent New Yorker article by Jessica Winter, Winter writes about Lindsay Clancy who suffered from postpartum psychosis. Lindsay, a 32-year-old labor and delivery nurse at Massachusetts General Hospital on January 24, strangled her three children, ages five years, three years, and seven months while she sent her husband to a restaurant to pick up takeout food.
In my opinion, Lindsey had been suffering from postpartum depression, postpartum generalized anxiety disorder (GAD), and postpartum psychosis for some time. She had sought help from various places on numerous occasions. That she couldn’t find the care she needed is inexcusable.
To me, it is extremely clear that Lindsey Clancy fell into the hole between obstetricians and behavioral health. It is true that obstetricians aren’t trained in mental health issues and that psychiatrists aren’t trained to treat obstetric patients.
First off, Lindsay knew she was in trouble. She tried meditation, she tried outpatient mental health treatment, and she tried inpatient mental health treatment. Systems errors are rampant in our healthcare system, with repair nowhere in site. This is especially true of postpartum depression.
The CDC says that 82 percent of patients who die in the behavioral health group are either in or have been during the last year receiving mental health care. These patients are going to the right places, but they are not getting what they need, as we can see with Lindsay. Only 3 percent of patients with postpartum depression are treated until they are cured, according to the CDC.
Just before Christmas, Lindsay was evaluated at the Women and Infant’s Hospital Center for Women’s Behavioral Health, in Providence, Rhode Island where she was not diagnosed as having postpartum depression, but she was likely misdiagnosed as having in general anxiety disorder (GAD.)
There is the general misconception that postpartum depression and postpartum psychosis are both mysterious and surprising. After over 40 years of listening to 6000 moms and 6000 dads and helping them to manage their pregnancy and postpartum mental health issues, I can tell you that this problem is neither mysterious nor surprising. It is simply, for the most part, not treated. That’s because nobody owns it. In my experience, postpartum depression is reactive. In other words, it is a reaction or maladjustment to specific tangible events described in Winters’ article.
I’m describing specific real factors and expectations which precede postpartum maladjustment, leading to postpartum depression and postpartum psychosis. According to ACOG (the American College of Obstetrics and Gynecology) baby blues are common in women, starting between two days and seven days after delivery. If the baby blues do not resolve during this period of time, women move into depression, beginning after the baby blues and ending in about six months. If the postpartum depression does not resolve after six months, postpartum psychosis follows.
Moms and dads who resist change in routines or resist adaptation to the changes the new baby brings into the household create much more work than is necessary. Thinking that everything should continue as it had prior to pregnancy and delivery of the new baby is rigid thinking, sometimes called brittle thinking. Maybe, the dishes aren’t done or the house isn’t cleaned. Maybe mom doesn’t need to feed the baby all the time. Have dad take turns feeding the baby. Postpartum should be an active sharing process. The new baby changes everything and is a new opportunity to change as well.
If Lindsey had come to my office telling me that she was up at 12:30 1:30 and 3:00 am with baby and then planned to get up at 5:00 am for meditation, I would have told her this was a recipe for disaster. You need your sleep. Sleep clears away the cobwebs in your head and allows for better executive function, which includes reasoning.
The other adjustment that absolutely must occur postpartum is division of labor. Although Lindsay doesn’t tell us why she’s getting up at 12:30 1:30 and 3:00 am, it could be that she’s breastfeeding. At two months, the baby should be waking up once or twice a night to eat. There’s absolutely nothing wrong with having the father get up with the baby half of the time. Dad can also prepare food, do the dishes, clean the breast pump, and help take care of the other children.
There are some people who at least recognize the turf problem between obstetrics and psychiatry which creates the postpartum gap in care. If the groups trying to figure out how to prevent postpartum depression recognize the turf problem and agree to try to do something about it, training psychiatrists or psychologists in the postpartum world will probably take a decade or more to accomplish. Likewise, the same is true for obstetrical training. The idea that obstetricians are not responsible for patient care after 6 weeks is entrenched in medical school training and it will take years to turn this thought process around. We are looking now at frequent psych testing during and after pregnancy, but patients don’t like mini-mentals. What’s more, these tests don’t predict postpartum depression. They only indicate whether a person is or is not depressed. Patients will tell us that they would rather have somebody listen to them than fill out an impersonal questionnaire. Talking with patients and listening to what they are struggling with is far more effective in identifying whether or not a patient will develop postpartum depression and in helping patients look at their reaction to change and see opportunities for improvement.
For many decades I would see my patients as often and as long as they needed, whether insurance paid for it or not. I had also developed a good relationship with an excellent psychiatrist who I could call at any time and discuss possible treatments when I observed the signs of postpartum depression, whether it be talking, medication or both and plan for follow-up which would include a visit with a psychiatrist within one week.
Together we would manage the postpartum care of my patients and keep each other informed. This was a relatively simple thing to do until the introduction of electronic medical records which destroyed good communication channels by splitting up one action into half a dozen unrelated pages users can’t find once the Enter key is pressed.
When my patients came in with concerns of postpartum depression, we discussed the easy little things like not making work out of feeding the baby, sharing jobs with your significant other and maybe letting some of the cooking and housework tasks slide for a little while.
There are many tangible solutions to the kinds of problems with daily living that lead to postpartum depression. Years ago, one of my patients complained about the trouble she was having with getting her four-year-old boy dressed. Her two-year-old girl was not a problem. Her four-year-old wanted to pick out his own clothes. The mother was worried that he might mix plaids and stripes. Although I couldn’t get her to drop all of her control issues, we did come to a workable compromise. I advised her to pick out two outfits she could tolerate for her son and let him choose which set of clothes he would wear. As it turns out, the boy was actually quite agreeable to choosing from the outfits his mother set out. This decreased the anxiety of the mother and was a simple way to resolve unneeded, unnecessary tangible conflict, something which can lead to postpartum depression.
Postpartum psychosis can last a long time and can be benign. Forty years ago, an elderly lady came to see me. She was late for her appointment and apologized. She told me she couldn’t ride the bus that day because people on the bus could hear her thoughts. So she had to walk to my clinic. I asked her how long people had been able to hear her thoughts and she said since the birth of her last and seventh child. This lady had a postpartum psychosis that had lasted for several decades. Fortunately, it was benign and really didn’t hurt anybody except for the lady herself, who was only mildly disturbed with her problem. I didn’t argue with her as it does not pay to disagree with someone who is demented or psychotic.
Finally, I have sympathy for Lindsey Clancy, her children and her husband. Winter in her New Yorker article represents postpartum depression and psychosis as mysterious and surprising. This illness is neither. Most often it can be avoided. Suicide, homicide, or drug overdoses are permanent solutions to temporary problems. My hope is that this systemic gap in medical care or postpartum mental health will be recognized for what it is and treated appropriately by the people who are in the position to bring about needed change.