Magnitude of postpartum depression unheard of – reproductive psychiatrist

SS: So I see your point, but once again, I want to give you my example because my pregnancy, I think, was a dream pregnancy in a way that it was during the pandemic. So I had a chance to be in a beautiful house, my parents next to me, getting a lot of help, with a beautiful backyard, having walks every day, eating by the hours, sleeping really well. So in terms of how stressful my pregnancy was, it really wasn't stressful and I still got a postpartum for two and a half, maybe three weeks. Are there women who are more prone to postpartum than others?

JN: Absolutely. And that's the research I was alluding to earlier. There's been research that inquired about this or explores this after the fact where you take women with histories of postpartum depression, and then those who have had babies without developing postpartum depression. And you put them through an experimental protocol, where you adjust their hormone levels in a similar manner, you do that chemically with medications. What you find is, again, there are many women for whom those hormone shifts don't appear to affect them in that way. But there's a subset of women who are vulnerable to when those things when those hormone levels shift so abruptly, and particularly when certain of those hormones not just change but fall dramatically. Absolutely, that's the case for some women.

SS: You know, can postpartum depression be averted somehow? Is there some preventive therapy like, you know, taking particular vitamins, doing yoga during pregnancy, which I actually did, eating hormonal supplements right after? Is there anything to prevent that? Or it's out of our control?

JN: No, absolutely, there are preventive measures that can be taken. And again, when you look at the broader picture of all the different things that can come to bear. So for example, in terms of, you know, medicinal approaches that you can use, we know that contributors to postpartum depression include an array of things such as thyroid dysfunction, which can happen in the postpartum period, as well as anaemia, those sorts of things. So monitoring those things very closely in light pregnancy, and then rechecking those, you know, following delivery can be an early clue that someone may be susceptible. And then, of course, you know, preparing yourself for all of the social transitions, that come up during the course of having a baby. So ensuring that you have proper social support, realistic expectations, those sorts of things, and counselling can come to play. In terms of the contribution that these rapidly changing levels of estrogens and other hormones play, there's not really a preventative measure you can take other than being aware of that possibility and when it does arise then being able to very quickly make use of the treatments that can reverse that process so that there's not a delay in access to care.

SS: Okay, what about treating it once you have it? I mean, when you're breastfeeding, taking antidepressants is not an option. So what can you actually do to ease that state?

JN: So I would actually disagree with your statement that taking antidepressants is not an option when you're breastfeeding. When you're pregnant or breastfeeding, for that matter, and you have a health condition (right now we're talking about depression, we can be talking about anything from high blood pressure to epilepsy, to a variety of other health conditions), when you're making decisions about how to treat those health conditions, what you're weighing is the risk of leaving it untreated to both mother and baby, a baby within the womb or a newborn baby, and then you're weighing that against the risk of exposing the baby to a medication. And so one of the things that is very often, there's been this focus on depression as postpartum depression what we've learned over the course of the last 20 years is that postpartum depression is actually a bit of a misnomer in that many women experience depression during pregnancy. And when that's the case, then you have to take a look at what's the risk for mom and baby of the depression left untreated versus the medicine. And I will certainly acknowledge there is no medication, certainly no antidepressant, but no medication that is completely risk-free, if taken during pregnancy or during breastfeeding. But if you take stock first of the illness and what dangers it poses – and so we know that, for example, in pregnancy, depression left untreated triples to quadruples rates of preterm birth, birth weight, hypertension during pregnancy, ICU admissions for newborns are higher if the mothers are depressed during pregnancy, and so forth. And we know that postpartum depression interferes with mother-infant bonding that can lead to problematic developmental outcomes for children, contributing to childhood depression and anxiety. And so we get faced with these difficult situations where if we don't treat, then the baby is at risk. And it may be that non-medication treatment such as yoga, exercise, psychotherapy, and that's always the first line of treatment, but sometimes those are ineffective. And then we find ourselves in these situations from time to time, where, even though the medication may carry some risk to the baby, starting the medication, taking the medication while pregnant, or while breastfeeding may actually be safer for the baby because it provides some protective benefit against the illness. And we face the same sort of thing with a variety of other illnesses. So this is not unique to depression. The same thing comes into play, for example, I mentioned epilepsy earlier. You know, anti-seizure medicines are quite risky to take during pregnancy and breastfeeding. And yet, we know that because having seizures when you're pregnant, or when you're holding a newborn baby is so dangerous, we routinely recommend that women with epilepsy continue their medication. And so to a lesser extent, but still, sometimes we find ourselves in positions where medication has to be recommended.

SS: I feel like postpartum [depression] is sort of downplayed as something that, you know, you get, it's normal, and you'll just get over it, it will go away. But you know, I've heard some cases, maybe 10 or 15% of women actually get clinical depression after that if not treated. 

JN: That’s correct.

SS: I know some extreme cases where a woman, you know, went as far as commit suicide during the postpartum. So would you recommend treating it to all the women or just those who feel like they're in need?

JN: So there is a continuum, there is a mood disturbance after delivery, called postpartum blues, or sometimes it's called baby blues, which is experienced by over half of women, you know, sadness, being very emotional. But by definition, baby blues, postpartum blues only lasts three days, and then it will resolve. Beyond that, then, you know, when you're looking at something that's going to last weeks, then you're in a position where now this is not a normal thing. This is an illness. And now sometimes, you know, the illness of depression, because it is episodic, will spontaneously resolve, which, you know, fortunately, that was your experience, it didn’t last. But there are other occasions where that postpartum episode or depression, I mean, I've been referred women who were more than a year past, you know, their baby was more than a year old, and that postpartum depression had never gone away. And it can set up for some long term chronic problems. And so because of that, yes, for those normal mood disturbances – just the support and encouragement. When it begins to unmask itself as an illness that has the potential at least to be long-lasting than then intervening with treatment is important. And that doesn't necessarily mean the treatment has to be medication. You know, the first line of treatment, like I said, is one that does not entail medication exposure to a baby, which would be a form of psychotherapy, so meeting with a trained therapist. And there are a variety of psychotherapies that have been adapted for use in women during the postpartum period: I mentioned interpersonal therapy earlier, certain forms of cognitive behavioural therapy and the like. And then the biological treatments, the medication treatments then are that last line of defence when other things are not bringing that depression into resolution.

SS: You know, I've often heard from like, older generations that fancy words like postpartum depression is something that we made up in our new reality, a new world and back then when, you know, in the 60s or 50s, and 40s, or even 70s, people didn't even know such thing as postpartum, it didn't exist, that they just gave birth and got on with it. Is there any truth to that? It? Or did it just become a thing because we have a name for it? Or they had it too, but they didn't acknowledge it? And if they did have it, then could we get some pointers from them maybe?

JN: So it's funny that you bring that question up, because in a chapter that I've written for a textbook several times, I point out that when we look through the ancient literature, we actually find the first mention of postpartum depression in ancient Greece by Hippocrates. And so the founder of modern medicine, although we call it modern medicine it is very ancient. So we see that mentioned, you know, millennia ago. And then, with more publications, The Marcé Society is one of the leading worldwide groups of healthcare providers who work with women during the postpartum period for postpartum depression and anxiety and it's named after a gentleman who studied and wrote about postpartum mental illness back in the 1800s. So no, this is by no means a new issue. Yeah, it is one that you hear more about, because the magnitude of it, in terms of the frequency, and the numbers of women who experience that, is something that has been studied more carefully. And you mentioned the numbers, as many as 10 to 15% of women will experience a clinical depression during the postpartum period. If you go back several decades ago, we knew that postpartum depression existed, we had no idea that that was the magnitude of how often it’s heard.

SS: Is it easier to maybe deal with postpartum or baby blues when you're older and wiser like me, for instance? I’m 42. And in general, do you feel like there is an age limit to when a woman should give birth to a baby? Because times have shifted, you know, like, giving birth to a baby at 40 is really nothing anymore, everyone does that. Even 45, sometimes 47. 20-30 years ago that would be unheard of. So is there in your professional medical opinion, a time limit, after which a woman shouldn't give birth to a baby, because she can't cope psychologically?

JN: So there's certainly no time limit with regard to contributing to depression where at a certain age, you should not be having children. I think it's what's most important, though, is to educate people about the things that they may face, so that they can make the best-informed decision as to whether or not to proceed with a pregnancy, but recognising that even when people are educated, there are times where the way that they respond emotionally to being a new mother is not at all what they anticipated. So, for example, you know, if we use the example of women who are a bit older and established in their lives and established in their careers, what I have seen through the years is typically women who are having their first child and have already established a career, you know, will face a choice as to ‘what am I going to do with my career when I have a child?’ And some will opt to continue their career unabated and hire other folks, or have extended family members help provide care for the child. Some go the other way and say, you know, ‘when my child's young, I want to put my career on hold temporarily and be the primary caregiver for my child’. And then all points in between. But the thing that I've noticed is there are times where those plans are in place and yet, once they have the baby, they find that what they had planned is not what they want. So I've seen those who had planned to put their career on hold and were just bored and miserable, they love their baby but missed all of that activity, and decided ‘no, I need to shift back in another direction and have my career remain more active.’ And I've seen the opposite, those whose plan was to have the baby, ‘take my maternity leave, and then return to work’ and were miserable with that plan and changed. And so I think educating women as to what are the issues and decisions that they're going to face once they have their baby, and to make a decision as to what their plans are but to prepare them for the possibility that once they have their child that their opinion and approach to that may change. And it's not for me to dictate to them what works best for them and their family.

SS: Alright, so another huge topic is the hardcoded biological fear for your kid. I never knew that before I've had him. And then all of a sudden this little being comes to life and it is constant. I mean, in the middle of the night, right now I'm talking to you, he is with a wonderful nanny and my mother at the same time, I know he'll be fine. But I'm parallelly thinking, ‘What is he doing? Is he okay? Is he sneezing? Is he burping?’ This fear, the sort of alertness inside you, it's exhausting. What do you do with it? I mean, I theoretically understand that it's probably not good for the baby either because they say that mother's fears always transmit to the kids, they're transferred on to the kids. So I'm not sure how to deal with that. ‘Cause it’s just there, it's in me, I can’t help it.

JN: Yeah. So there's anxiety that is symptomatic of a problem, of an anxiety disorder when the anxiety is disproportionate to the actual threat or circumstances that are what's going on. But, you know, anxiety can also be existential, it can also be part of the normal course of human experience. My point being, there are times where it's appropriate to be anxious and it's appropriate to be cautious. And so I don't think it's wise for us to – our quest to be to eliminate all anxiety, because that can then leave us making ill-informed decisions and so forth. And, you know, what I've observed in terms of that existential parental anxiety, it never goes away. And my children are now in their 30s and late 20s and, you know, the frequency at which I worry about them is not the same as when they were just a few days or a few weeks old, but it never goes away. And so, it's about finding that balance. One of the things about anxiety that separates it from depression is anxiety is always oriented towards the future. One can be depressed about things from the past or present, or future but anxiety is always about the future. Even if it's a past event, the anxiety is focused on what are the implications of that going to be going forward. And there's nothing that generates more anxiety than uncertainty, and not knowing. And so even more so than for depression, one of the keys to managing anxiety is education, is learning what to anticipate in going forward. I think that's a big part of why susceptibility to severe postpartum anxiety is less often seen in those who are having their second or third or fourth child than the first child because everything is so new, there is so much uncertainty. And that's where things like postpartum peer support groups can be very, very helpful. So that you're talking with other individuals who are going through that and experiencing that, and you're benefiting from their experience. And, you know, the more that you learn about what to expect and alternatives for how to manage these things, and it doesn't have to be with a formal peer support group, but just from your peers, be it family members or friends, and you share information and you learn from that and you benefit from that. That really helps alleviate, you know, a lot of that existential anxiety and then by extension protects you from that expected real-life anxiety from morphing into an anxiety disorder.

SS: Professor Newport, thanks a lot for this wonderful insight. You've actually really helped me a lot, this wonderful chat, and I hope we get to do this again because this is a never-ending topic for me, especially now that I've had a baby. So thanks a lot. Thanks for all the wonderful work you're doing and good luck with all your future endeavours. 

JN: Thank you so much. I'm grateful for the opportunity to speak with you.

SS: Thank you.