Maternal Mental Health Explained: A Conversation with CentraCare Psychiatrist Claire Drom, MD

The following is an excerpt of Dr. Claire Drom's interview with WJON's Jay Caldwell. Dr. Drom, an adult psychiatrist, has a special interest in treating psychiatric conditions and symptoms of women who are thinking about becoming pregnant, who are pregnant, or who have just had a baby and are now in their postpartum period.

Question: When a woman becomes pregnant, there seems to be a lot going on. How does that affect her mental health?

Dr. Drom: You hit the nail on the head. There's a lot going on during and after pregnancy, especially with hormone changes in the body. These hormones can increase the risk of depression and anxiety. Pregnancy also brings about physical changes and changes in identity. Just getting around in the world as a pregnant person and a new mom is different than before having a kid. All these biological and social factors interconnect and serve as risk factors for developing psychiatric symptoms. Some other risk factors include having a personal history of mental illness before pregnancy, coming from a marginalized background, having a lower socioeconomic status or being in a community of color. Family history can play a role, too.

Question: Do hormones affect mood and behavior during pregnancy?

Dr. Drom: We think hormones affect mental health the most around the time of delivery, where there is a big drop in progesterone and types of progesterone. This drop is very clearly associated with the risk of depressive symptoms.

Question: Does working or continuing to be active have any effect on maternal mental health?

Dr. Drom: I think that's going to be different for every person. Typically, being able to work brings personal enjoyment and fulfillment, whether that work is in the home or outside the home. So being able to continue these activities is often protective against mental health symptoms. At the same time, being pregnant in the workforce can be difficult. For example, it's physically harder to move around. It's difficult to get time off for medical appointments. If somebody has a lot of physical pregnancy symptoms like nausea, headaches or pain, it can be sometimes difficult to change work hours. So those are particular sources of stress for pregnant moms. And depending on how they're able to navigate that with their employer, if that goes poorly, that creates a lot of stress. When there's that conflict between needing to work, being at work and needing to adapt to changes from the pregnancy itself, it becomes a major risk factor for development of depression and anxiety.

Question: People assume being pregnant is a reason for excitement and optimism, but what would cause a woman to be depressed?

Dr. Drom: This is an area of knowledge that draws from a lot of different fields. Not just medical science, but also philosophy and sociology, meaning how we interact in society. We used to think being pregnant was protective against mental health conditions. What we've seen more is that for many people who develop depression or anxiety is that it occurs during pregnancy. So, when we look back, only about 40% of folks developed their symptoms after delivery and the rest had their symptoms during pregnancy. That dispelled this idea that pregnancy itself is protective. People can be excited about pregnancy, want to be a parent and be very invested in that and still experience depression.

Having that depression is difficult for people, having that conflict within them of feeling sad, yet at the same time not really feeling like they should be sad or can be sad. And that's a significant source of distress and a really big reason people don't talk about it because a lot of the feedback that they get is, "Well, you're pregnant, you should be excited. Why are you sad?" And so that kind of dismisses what's going on and they just kind of keep it to themselves.

Question: What are the signs of depression that you should be looking for in pregnant women?

Dr. Drom: This is really important. So, like we talked about earlier, pregnancy is associated with a lot of physical changes. Just from growing a human, women may have aches and pains. They may be slower; their appetite can change quite a bit. They may not feel like eating. Their sleep can change, their body can change. These changes can be normal.

However, for symptoms of depression, you will want to watch for things that may not be normal, such as feeling inappropriately guilty, such as thinking "I'm a bad person, I'm going to be a bad mom, I'm going to be a bad parent." Other symptoms are feeling unattached to the pregnancy, totally disinterested in what's happening, crying all the time, not being motivated or wanting to do things unrelated to physical symptoms that might make you uncomfortable and unable to do things. And then there are suicidal thoughts or feeling that someone would be better off dead. These thoughts are always abnormal and a red flag for getting help.

Question: What should you do if someone you are close to has these symptoms?

Dr. Drom: I think people around a person with depression might recognize it more quickly than the person experiencing the depression. And of course, you don't want to insult or offend someone by bringing it up and yet you're very concerned at the same time. So, I think a couple of things that people can do is to open the line of nonjudgmental communication and say, "Hey, I'm here for you. Let's go get a coffee, go to the park, get out of the house and spend some time together." There also are resources out there that can give loved ones really good advice. I always direct folks to Postpartum Support International. They have a big website with lots of ideas about how to approach folks who may be having symptoms. I think a simple, "I'm really worried about you. I care about you. You don't have to be alone in this." That kind of gentle reassurance given over time can really be very helpful in increasing someone's ability to open up and seek help.

Question: Does being depressed while pregnant lead to postpartum depression?

Dr. Drom: Postpartum depression has gotten wonderful press coverage, and it is on everyone's radar. However, anxiety and other mental health symptoms following delivery are just as common as depression. It is likely that if somebody has symptoms starting during pregnancy, they will continue to have symptoms into the postpartum period. Approximately one in five people who become pregnant and give birth will experience one of these disorders. They affect about 800,000 families in the United States each year. Some data suggests symptoms can persist and last for up to three years following delivery of the baby.

Question: If someone is dealing with postpartum mental health, what are some of the obvious signs?

Dr. Drom: In the postpartum period, we see more women who make statements about how they are afraid to be with their baby, do not feel like they are bonding, or the baby was a mistake. While all new parents are fairly sleep deprived, parents with postpartum depression or anxiety will say they feel so exhausted they cannot sleep even when their baby sleeps. These kinds of statements are really significant.

This may be a suitable time to talk about the baby blues. The baby blues is a period within the first couple of weeks after delivery. It is a normal period of transition with the hormone shift we talked about earlier. During this time, women may experience emotional sensitivity. They may be crying, laughing or emotionally all over the place, not feeling like themselves. I always give the example of after my first kid was born. I made toast, and it popped out of the toaster, and I started crying. This can happen in the first couple of weeks after delivery, and it is normal. What is not normal is if those symptoms persist after a couple of weeks with those other factors such as guilt, lack of interest in the baby or not wanting to take care of themselves.

Question: What drives a parent to want to do harm to a newborn?

Dr. Drom: I want to begin by explaining the difference between psychosis and intrusive thoughts. Intrusive thoughts are common in all new parents — moms and dads. They are when you are going about your day and then suddenly a thought enters your mind. You might picture yourself walking down the stairs with your baby and you trip and fall. It is usually scary and upsetting. You are not really in control of this thought's existence and the thought is unwanted.

For people with postpartum psychosis, they may have more delusions, where they have unusual and irrational beliefs related to needing to do something to protect their baby or achieve something else by harming their baby. They may not feel discomforted by those thoughts. Postpartum psychosis is exceedingly rare, but it is a significant emergency because the risk of harm coming to the mother or the baby is remarkably high.

Question: What are the consequences if women are seeing some of these symptoms and they do not address them?

Dr. Drom: Depression and anxiety can have significant impacts on the family. If depression or anxiety is not treated there can be increased rates of substance use, difficulty engaging at work and downstream financial complications if somebody can't stay employed in the family. Moms can have their partners develop mental health symptoms as well. There can be lots of conflict in the family and that really affects the kids and the child's development. One major alarm that we're seeing in this country is that suicide and overdose have become the leading cause of death of women in pregnancy the first year following childbirth, so it's really an urgent matter.

I'd like to just convey that this is such a common issue. Chances are you know someone in your life who has experienced one of these disorders. Having one of these disorders does not mean you are a bad or unfit parent, similar to how developing diabetes or high blood pressure from pregnancy doesn't mean you're a bad parent. This is a common medical issue and there are ways to make it better.

Postpartum Support International has a database of practitioners in the community who are comfortable treating these conditions.