Having a baby is an exciting time for most families. They bring so much joy to a woman’s life. It can also bring a lot of stress whether you are pregnant or postpartum and in some cases, contribute to perinatal mood disorders. According to Women’s College Hospital’s Women’s Health Matters site:
“Women are at a higher risk for both new and recurring mood and anxiety disorders. This is even true for women who have no prior history of mental health difficulties. The two most common perinatal mental health difficulties are depression and anxiety. In fact, 80 per cent of new mothers experience “baby blues.” And, while the lifetime rate of depression for women is around 20 per cent, the majority of these episodes occur during a woman’s reproductive years.”
Baby blues are common and are the result of hormone shifts during and after delivery. Postpartum depression is much more serious and involves one or more major depressive episodes. To learn more about the differences and the risk factors, check out the Women’s Health Matters website.
The Run for Women, brought to you by the LOVE YOU by Shoppers Drug Mart program is a 5K Run/Walk, and 10K Run taking place in 18 cities across Canada on September 27th. This year, the program, which supports 18 local charities providing critical mental health support and care across Canada, is going virtual. This is all about supporting women and the healing power of a loving community. In Toronto, the funds will go towards Women’s College Hospital’s Women’s Mental Health Program. We recently spoke with Dr. Simone Vigod, Psychiatrist-in-Chief at Women’s College Hospital and an internationally renowned researcher at Women’s College Research Institute about maternal mental illness, what the options are and why The Run for Women is so important.
Most women are familiar with postpartum depression. Why are other perinatal mood disorders still not widely discussed?
Part of what has happened is postpartum depression has become a euphemism for any postpartum mental health issue. That is natural, because people are more familiar with it. Various celebrities, like Brooke Shields, have admitted to postpartum depression. That leant a lot of demystification and normalization around this concept. That it was OK not to be OK around the time of pregnancy and more particularly, after birth. Mental health issues come with a whole set of beliefs and attitudes. A lot of people feel stigmatized by having a mental health issue – there is a lot of shame associated with it. I think that in the early days, that’s what the term postpartum depression did. It doesn’t mean that there is something wrong with you if you have this and also, we know how to treat it.
Over time, the problem is that there are many different kinds of mental health issues that happen during pregnancy and postpartum. Any mental health issue or addiction can happen during pregnancy or after delivery. Unfortunately, what has happened over time, is that postpartum depression got really popular as a way to conceptualize the whole set of factors. If women had depressive symptoms during pregnancy, they may have starting thinking that wasn’t a “thing”.
We are almost certain that postpartum anxiety is more common than postpartum depression. There are a lot of women who have had traumatic experiences early in their lives that get reactivated during delivery and then have Post Traumatic Stress Syndrome (PTSD) diagnosed postpartum. It also looks like it’s more common to get OCD-type symptoms postpartum like needing to clean and doing repetitive activities to calm down. I think part of what is happening now is that women are saying “Wait – I can’t see myself in postpartum depression. That’s not reasonable.” In fact, if you add up all of these other things combined, they might be even more common then having a depressive illness which is by definition sad, not motivated and feeling really guilty. That happens too, it’s just not the only thing.
I think it’s a little of the translation from the clinical to the public. Mental health professionals have always known that you can have any mental health issue but there is a little lost in translation and women advocates are starting to say, wait, I want to see myself in my symptoms and rightly so.
Are there any risk factors for perinatal mood disorders? Who is most vulnerable to them?
Absolutely. It hasn’t been shown that pregnancy itself necessarily increases the risk for a perinatal mood disorder. But pregnancy is a time when a lot of people who had pre-existing mood disorders stop medication. If they have had a severe illness and stop medication abruptly or they were using it to stay well, they can be at high risk. For some women, stopping medication is going to be a risk factor.
In the postpartum, that’s where there really is a spike of unusual levels of depression and anxiety and we think that some of that is genetic, heritable-biological. Clearly, some women have a sensitivity to the rapid hormonal shifts that happen during the time of delivery. If a woman has a previous history of a mental health issue, if she has a family history of a mental health issue, particularly mood disorders like bi-polar disorder and depression, that may be an increased risk for her.
In addition, some of the social and psychological issues that happen in the transition are risk factors. That can include lack of sleep, the stress of having a sick baby, having severe marital discord or domestic violence and having major financial pressures. You can imagine what the pandemic is doing to stress levels. The third major risk factor is social support. Social support when it occurs is extremely protective and can prevent postpartum depression and anxiety in some cases. Lack of social support, whether that is practical or emotional is a really strong risk factor for someone developing postnatal depression or anxiety disorder.
What steps should a woman take if she has had a history of depression and is pregnant or finds that she is feeling overwhelmed during or post pregnancy?
Women and their partners ask me this all the time. The very first step is “How do I know if I’m just feeling overwhelmed or if I have a mental health problem that requires treatment?” What I say to people is that it’s about the severity of how overwhelmed you are feeling. If you are having thoughts of not wanting to be here for example, even if it’s fleeting, that is severe and you should reach out for help.
The other thing that I talk about is stickiness. If you feel overwhelmed, but a few minutes later, after you go for a run or talk with a friend or just have a chance to take a shower and you feel back to your baseline, that’s a good sign that this isn’t spiraling into mental health problem that might require ongoing therapy or medication. If the issue is really sticking, you can’t shake that mood and with postpartum women you can’t sleep even when your baby is sleeping, you can’t shut your mind off and you have really negative thoughts in your head that you can’t just shake, that’s when it’s really important to reach out for help.
There are so many things that can prevent perinatal mental illnesses like interacting with others, having support, taking time for yourself and getting good sleep. If somebody is feeling a little overwhelmed and having mild symptoms, those things are going to be really helpful. When someone is in the position where they have more low days than not, they are so anxious they can’t sleep even when the baby is sleeping or they are having very severe symptoms, that’s when we should be looking at a treatment. By treatment, I mean therapy with a trained therapist. In more severe cases, if therapy doesn’t help a person enough, then that’s when we start to talk about medication.
We are in an age where people share their lives for better or worse on social media. How does this affect the average woman mentally?
It’s tough. As much as some women know logically that some posts are sanitized, it hits at a deep emotional level when you are pregnant or you are postpartum especially, the first time. There is so much uncertainty with pregnancy and parenthood. You have to make all of these decisions all of the time. You don’t necessarily know what the best or right answer is or if there even is one. There wouldn’t be 30,000 books written about pregnancy and parenting if there was one right way to do things. Every time you see something like this with somebody “looking like they are doing it better than you”, it can really hit and twist inside. You can go down a spiral where you convince yourself that you aren’t good enough.
There have been some studies on social media where there might be a U-shaped curve. Some is good, because you want people interacting with others, but if you are on it too much, it becomes very hard to separate yourself and give yourself a reality check. We see a lot of women who have had difficulty, whether it’s online or part of Mommy groups and my advice is always if you are feeling like that in a group, maybe you need to find a different group where people are being more realistic. If anyone is saying that things are absolutely perfect all of the time, and they are always making the right decisions, that is few and far between.
It’s hard because everyone wants to do their best and I spend a lot of time with parents talking about Donald Winnicott a pediatrician who in the 1950s coined the term “good enough mother” [we talk about “good enough parent” now]. The whole idea is that you don’t have to be perfect, in fact, you don’t want to be perfect, because what you want to show your child is that you can be imperfect and flexible and still feel like you are doing a good job. That’s what you want to model for your kids, not that your child has to do everything perfectly or they are worthless. What we want to say is you can try, and persist and correct and everything is going to be OK and you are worthwhile even if this one outcome isn’t good enough. That’s the approach that we try to take with parents.
Social media is all consuming and during the pandemic, people have not had social support, person-to-person interaction, so a lot of life is online. I encourage mothers to look at the other side of social media because people also post pictures about what it feels like to be very pregnant or running around after a two-year-old all day. If you look for the other stuff, that’s there too.
What impact has COVID-19 had, generally speaking on women’s mental health, particularly with new and expectant mothers? How has it changed your own practice?
It’s one thing to worry about COVID itself, and with a lot of viral illnesses, there is uncertainty about whether pregnant women might be more susceptible to catching it or have more serious complications as a high-risk group. Then, there is the anxiety of having a new baby during the pandemic. The evidence and research from past pandemics suggests that often, it’s not the virus itself or the fear of it that takes the biggest mental health toll on the population. It’s the containment effort.
What we’ve seen since the state of emergency was declared in the middle of March is broad social and financial disruption. Pregnant and postpartum women don’t have help. They may be more worried about finances; their partners may be struggling too and that could lead to domestic discord. In addition, healthcare services have been different so pregnant women don’t get to have their partners come in with them for appointments. There were periods of time where during delivery, support people were only there for short periods of time. All of the community-based supports that we have in place that we know prevent postpartum depression and anxiety weren’t happening. Lactation clinics and even postpartum support groups weren’t available. We added stress and took away support.
There is a group out of Calgary that did a survey in April and May of pregnant women. Close to 50% of women were reporting elevated levels of psychological distress. Whether that’s a mental illness, we can’t tell from a survey, but certainly elevated levels of psychological distress are going to put them at risk. We have had increases in referrals to our clinics. Looking at Ontario data, visit levels for postpartum women to family physicians and to psychiatrists for mental health issues, mainly depression and anxiety, have been increasing. It’s been a rough time for pregnant and postpartum women and for parents of young children.
Pregnancy and postpartum are one thing, but there are so many vulnerabilities in our society that may make people doubly vulnerable. Maybe they were already poor, maybe they were an immigrant or from a racial or ethnic group that already had disadvantages in health or in the system, and these disadvantages can get compounded. Even around things like being able to offer people virtual care. Digital care is amazing, but people are talking about it in terms of the digital divide where there are some people that are going to get left behind if we aren’t careful.
What would you say to a woman who doesn’t know how to reach out or where to look for help?
The first thing to remember is if you aren’t doing well, that is a valid feeling and there are treatments and help for it. It is important to give them some de-shaming and destigmatizing language about this and give them hope that they can improve. Then I would recommend Postpartum Support International’s Canadian page, so women from anywhere in Canada can reach out and get connected to local services. They can also connect you with online postpartum support groups.
People can reach out to their family doctors, their midwives and obstetricians who can provide some healthcare, especially in primary care with the family physicians who have access to support groups and social work therapists and then, if needed, can refer people to mental health professionals for therapy and treatment.
What resources are available at places like Woman’s College Hospital to help a woman deal with any type of maternal mental illness?
We run a specialized program called “Reproductive Life Stages Program” and it’s been in existence for over fifteen years. We see close to 2,000 women every year, referred by midwives, obstetricians, family physicians, pediatricians and psychiatrists who come in and will have a consultation with one of the psychiatrists. They will work with the woman to come up with a treatment plan within our own program which includes therapies, group therapies both in pregnancy and postpartum, mother/baby therapies, couples therapies and we’ll work with women for whom therapy isn’t enough and they may need medication.
We also developed an online postpartum therapy group that is facilitated by our trained therapists, called Mother Matters and women can self-refer to that by signing up online. One of our therapists will contact them to make sure that the program seems right for them, and get them engaged. Mother Matters is an online forum that women can look at or post on 24/7 and therapists will go back and forth between the forums. We usually have between 20-25 women in one forum. Each week, ] the therapist, will put out information to start a discussion and the therapist will stay in the background to check in with people who aren’t doing well who may need to come into our program formally.
It has been really helpful and efficient for us because we can treat women from all across the province. It’s helpful for women who have been struggling, who may have some depression and anxiety but don’t necessarily need psychiatrist. That’s been a successful program because out therapists facilitated it – it’s more treatment than a peer support group. Often some of the comments that women have on the forum is that they previously didn’t feel like they could access care and now they can. That’s the purpose and we fill up on that.
Finally, why is support for the Virtual Run for Women so critical right now?
This is an amazing way to create a sense of community, to help women know that they haven’t been forgotten about as they are in their isolated lives. The funds will go towards helping us figure out what we are going to do to deliver the best care to women. Right now, with this massive shift to digital care, we need to know does it work as well, who does it work for and how do we best deliver it? We made these huge changes because we had to, now we need be sure that we are keeping up and know that we are giving the highest quality of care. The only way that we can do that is through studies, research and training. This year more than any other year, it is more urgent that we focus on this population. I believe the direct translation for what we can use these funds to advance is so clear. If we make sure that the moms are OK, we will make sure that the kids and families are OK across generations.