Postpartum Depression: A View From the Front Lines

My town is home to Fairview hospital, the smallest land based hospital in Massachusetts. With its 24 beds and about 170 newborn deliveries a year, Fairview is a wonderful place. For years as a primary care pediatrician I examined newborns and attended many a delivery in the middle of the night. So after deciding(for reasons I have described elsewhere in this blog) to focus my behavioral pediatrics practice on the 0-5 age population, I went to pay my friends the maternity nurses a visit. What better place for a preventive intervention than the newborn nursery? I wanted to hear about the problems they were seeing and their assessment of what the needs were.

Recently I have been reading the most current research on the impact of postpartum depression on infant development. This reading is in the setting of the The Infant-Parent Mental Health Post-Graduate Certificate Program that I referred to in my last blog post. Quoting from the program's website:

This program is based on the award-winning Napa Infant-Parent Mental Health Fellowship Program developed by Dr. Ed Tronick, Chief of the Child Development Unit at Children’s Hospital Boston...Dr. Kristie Brandt, Director of the Parent-Infant & Child Institute in Napa, California...the present program is designed to address the increasing need for skilled, interested and appropriately trained professionals to provide infant-parent mental health services for families with children ages birth to five years.

Given what I am learning, the stories I heard from the nurses were alarming. I will diverge slightly to describe the research I am referring to before returning to my visit to Fairview. Much of the contemporary research has been done by Peter Cooper and Lynne Murray and is described in their book, Postpartum Depression and Child Development. In a more recent paper they write that considerable evidence exists indicating that postpartum depression (PPD) limits a mother’s capacity to engage positively with her infant. Several studies have shown that PPD compromises child cognitive, behavioral and emotional development. To quote them directly:

PPD is now recognized, by virtue of the distress caused to mothers, as well as the wider adverse impact on the family, as a significant public health issue...Since adverse child outcomes associated with PPD are more likely to occur in the context of chronic or recurrent depression, it is particularly important that this group be identified and targeted for intervention...It is crucial that attention be given in the treatment to the quality of the mother-child relationship and that specific therapeutic measures be introduced to help mothers engage optimally with their infants.

Back to Fairview. The maternity nurses estimate that 15 to 25 percent (and perhaps as high as 50%) of mothers delivering at Fairview have major mental health problems. These range from mothers carrying multiple psychiatric diagnoses such as bipolar disorder and depression, to those without a specific diagnosis but with multiple psychosocial risk factors. For this group of patients, nurses feel that 100% do not have adequate follow up after delivery. Mothers may have one home visit with a nurse. A part time social worker sees some of them prenatally, but there may no plan for follow up.

The distress in the room was palpable. The nurses worried for these babies, feeling that they often sent them home "on a wing and a prayer." They described one mother with a diagnosis of depression who gave birth to her third child. A two year old with no shoes sat strapped in a stroller , while a ten year old who was on multiple antipsychotic medications wreaked havoc in the hallway.

What would happen, I wondered with them, if I were to meet for one or two sixty minute visits with these high risk mother-infant pairs in the hospital?(more time than is usually available for an in-hospital visit by a pediatrician) My aim would be to forge a relationship between myself and the parents as well support the new relationship between the parent and her infant. In my pediatric practice I could continue to follow them when the almost inevitable challenges of crying, feeding and sleep problems arise. "When can you start?" they asked.

It would be a small intervention in a small hospital in a small town(to put it in place, the complex questions of diagnosis and insurance coverage must be ironed out.) One can only hope, however, that it would help to put a dent in what is potentially a very big problem.

Dyadic Therapy: Working with the Parent-Child Relationship

One of the things of which I am most certain, based on my years of practicing pediatrics together with my years of being a mother (and also just my experience as a human being) is that what children need most is for the people who love and care for them to understand them, and to be with them in a way that communicates that understanding.

For this reason, I have never understood why a young child would be ever seen in psychotherapy without his or her primary caregiver. Psychoanalytic theory contends that a young child has hidden conflict and fantasies that can be brought to light through imaginary play. This may well be true, but given the limited time and resources, is it really important?

This weekend I have begun what will be an intensive year long training in Infant-Parent Mental Health. Already I can see that perhaps the two most valuable piece of this experience will be one, to have this viewpoint validated by the world leaders in this newly emerging discipline and two, to be learning with a group of like minded clinicians from a wide range of disciplines, including social work, early intervention, infant massage, psychology, psychiatry and pediatrics.

This point was brought home for me yesterday when in our first full day we heard a case presentation and watched a video. Being ever mindful of confidentiality issues, I will describe only the basic points. The identified patient was a young child who had experienced significant neglect, with multiple losses and disruptions. This "dyadic therapy" we watched in the video was conducted with the child and adoptive parent together. The way in which both the setting and the therapist served to connect this mother with her very troubled child was magnificent.

Some of the most painful cases I have seen in my practice are those of children adopted out of situations of severe abuse and neglect. Parents come to me for medication when the children have been diagnosed with ADHD. When I hear these stories of terrible trauma, I work hard to convey to the parents that while medication may be helpful in controlling the symptoms, it is not sufficient.

Yet I immediately come up against intense resistance. The assumption is that I will recommend therapy. and the parents, for good reason, do not understand the purpose of individual therapy for such a young person. Yet a recommendation to work together with their child in therapy is also met with resistance. The difficult behavior is not their fault, and their loving and safe home should eventually cure the problems.

Here in lies the beauty of this program. My biggest challenge is a paucity of colleagues to refer to. In my community there is not only a shortage of child therapists, but even fewer who work from a conceptual framework that supports treatment of parent and child together.

My fantasy is that one day, when I see such a family, I will have a group of colleagues, all on the patient's insurance plan, who I trust to work to bring a parent and child together in the way I watched in that video yesterday. I know it's a dream, but at least as I sit with all of these colleagues who will one day be leaders in the field, I am hopeful that perhaps mental health care for children is moving in the right direction.

True Empathy: A Physical Sensation

Emily brought her son Micheal to see me when he was 3 and 1/2 months old. He had been born one month premature, but it was clear from a first glance that he was doing well. I remember noticing that his mother was so close, physically close. She hovered over his carriage, reluctant to let me pick him up. She stood inches from him while I examined him.

He was robust little boy who gave a big smile as he intently followed his mother's face. Emily felt he was doing well. So well, in fact, that she was attributing qualities to him for which he seemed to young. "It's good for him to comfort himself, right? I should let him cry, right?" She seemed very anxious.

About a year earlier, Emily had lost a baby, Christopher she called him, in her ninth month of pregnancy, when she was in a car accident. She conceived again almost immediately. And here was this miracle baby. I watched Michael sleeping in his blue jumper. He seemed so small and vulnerable.

"He's doing great," I said. Emily continued to wear that uncertain look as I tried to reassure her. She asked about sleep. "Is it OK if he is still in our bed? Is it good for bonding?" she asked. I was puzzled by this question and paused, asking her to tell me what she meant.

"Is he bonded to me?" she asked. I started to attempt an answer when she interrupted me. "Can you bond in utero? I mean I bonded to Christopher, but he died. I didn't let myself bond to Michael when I was carrying him."

I felt a tingling in my arms and a clutching in my chest. Tears came to my eyes as I watched them run freely down her cheeks. We sat this way for a while, living in the unbearable pain of her loss.

I thought of this moment when listening to Francine Lapides, in her terrific course "Keeping the Brain in Mind," explain the neurophysiology of empathy. It was an "aha" moment for me. Empathy is a commonly used word in mental health, and I admit to having used it for years without really appreciating its meaning.

Empathy, she explained, is largely mediated by a structure called the insula. It is predominantly a right brain structure that connects to the visceral organs-the heart and intestine. It also connects the brain with the skin and mediates sensations of touch and temperature. It is responsible for what is commonly referred to as a "gut feeling." Empathy, then, in its truest form, means to literally feel what another person is feeling.

Daniel Siegel, in his paper Mindful Awareness, Mindsight, and Neural Integration defines empathy as "the capacity to put yourself in the mental perspective of another person." It is not an intellectual understanding, as in "I understand how you feel," which is primarily a left brain activity.

True empathy, an actual physical experience, is somewhat rare. Empathy has healing power, both for the listener and the person being heard. It represents a profound attunement between two human beings. It is something to strive for in all relationships.

With Emily I wondered aloud if getting pregnant so quickly had prevented her from doing the difficult work of grieving the loss of her first child. She said to me, "I feel like I can't give all of myself to Michael. I have to hold back to protect myself."

At that visit with me, perhaps fortified by our moment of connection, of true empathy, she found the courage to face this task of grieving. She recognized it was critically important not only for herself, but for her relationship with her infant son.

Advice to Parents: Remember to Breathe

There is a well know saying in medicine that before doing CPR you should first check your own pulse. This very important point was brought home to me several years ago. I was on my way to a meeting at Austen Riggs, a psychiatric hospital in Stockbridge MA, when I noticed a large commotion in the hall. As I came closer, I observed many panic stricken people standing outside an office where a woman was in dire straits, in fact taking her last breath. Many of them were psychiatrists with MDs after their names, yet they seemed paralyzed. Perhaps this was because they knew her well, perhaps because they were used to talking rather than taking action, or perhaps it was a combination of both.

A friend who knew I was a doctor asked if I would help. As a pediatrician, I had never done CPR on an adult, yet I immediately took over. I lowered her to the floor and began CPR while simultaneously giving tasks to the others in the room. People moved carefully and deliberately. There was no shouting, no throwing of objects. Not only did she live, but her brain survived completely intact. The statistics for this kind of survival are 2-3%.

I am convinced that her unlikely survival is due almost entirely to my ability to remain calm in the face of this crisis. This calm, in turn, allowed all the participants, each of whom performed an essential function in the resuscitation, to think clearly and to get past the panic that had paralyzed them to inaction.

This blog post, though, is not about CPR, but rather a response to a friend's comment on my facebook wall. I'm new to facebook and haven't been in touch with her for a while. She wrote: "Where were you last night when I needed the advice of a sane parent??? OY...11 and 8 plied with sugar (?) is NOT good...OK, breathe...!"

Those of you who regularly read my blog will know I'm not a great fan of giving advice. First of all, I can't really understand the situation without having an actual conversation. Second of all, I prefer helping parents find their way back to trust in their own natural instincts over telling them what to do.

Yet I didn't want to come across as cold or uninterested. So after giving it some thought, I replied, "breathing sounds like a good idea!"

Staying calm in the face of a stranger's medical crisis is one thing. I probably learned this skill in the course of my years attending deliveries and taking care of sick children. But staying calm in the face of your own child's distress is quite another.

In my experience, both as a parent and a pediatrician, I am convinced that seeing your child in distress, and particularly if that distress is directed at you, is the most dysregulating experience there is. Wild, out of control thoughts of epic disaster come unbidden. Rage, self doubt and other destructive feelings quickly cloud your thinking.

What if you could work to push those thoughts aside, and in a way analogous to meditation, concentrated on being in the moment, concentrated on remembering to breathe? It would help you focus on your child, and on the immediate task before you rather than its global implications.

This exchange led me to think about my experience saving that woman's life, and to the idea that just as taking your own pulse is the most important part of doing CPR, remembering to breathe is perhaps among the most important things to do as a parent when helping your child through a child size crisis, whatever it may be.

Value Those Early Months of Parenting

Today in the Boston Globe I have an op ed entitled By the book, but breaking a bond, that is based on a previous blog post about the Massachusetts law enforcing 8 week maternity leave. Already at six am there are comments, and as is common when one puts ideas out into the world, some are none to friendly.

My aim in writing this piece, as well as one aim of my book (today I am sending the complete manuscript to my editor-thus the long absence from my blog) is to call attention to the critical importance of parent-child relationships in the early months of life.

When I see older children for consultation for behavior problems, I often hear stories from mothers who struggled terribly when their children were very young infants. Sometimes the memories are vague, but these mothers recall vividly the sense of being completely alone.

The most dramatic example of this was a mother with severe post partum depression whose father suddenly died when her baby was three months old. Much to my astonishment she described being relieved by this event. It wasn’t because she didn’t love her father. Rather, in sharing the grief with her siblings, mother and extended family, she no longer felt so terribly alone. In order for mothers to be available for the kind of preoccupation their newborns require for healthy development, it is essential that they not be left alone.

If I were to give one piece of advice to mothers, families and our culture as a whole, it would be to recognize that while what a mother does with her newborn may look ordinary, it is in fact extraordinary and deserves to be valued as such.

The relatively new field of Infant Mental Health has recognized this fact. The organization Zero to Three offers this definition if infant mental health, which is thought to be a characteristic of the child. “The young child’s capacity to experience, regulate and express emotions, form close and secure relationships, and explore the environment and learn. All of these capacities will be best accomplished within the context of the caregiving environment that includes family, community, and cultural expectations for young children. Developing these capacities is synonymous with healthy social and emotional development.” Research, clinical interventions and policy all aim to support parent-child relationships in the early months and years.

My aim is not to make parents feel bad for working, nor to imply that mothers need to stay home for years. Rather it is to bring readers inside those critical early months. My hope is that our culture as a whole will support, value and nurture parents of young children, parents who have the awesome responsibility for raising the next generation.