Mental Health Stigma Suicide

How I Started Treating Pregnant and Post-Partum Mental Illness & Why It’s Important

I’m going to preface this post with…nursing school was horrific. If any one reading this is a nurse; you feel me. If any one reading this wants to become a nurse…being a nurse is better than nursing school. Hang in there.

Maternity was mid-way through nursing school. Right when I felt like I was never going to get through the program but also feeling I had come so far and couldn’t go back now. I hated maternity. There were many reasons why but it was not my jam. First day in post partum I was given a patient with a fetal loss. I had to take pictures of the mom holding her dead baby.

Writing that now, I’m like wow that was definitely messed up. They had a nursing student manage this incredibly intense case on my first day on the rotation. Looking back I can see the rest of the time I was overwhelmed, and disengaged. Not only was I not interested but I felt somewhat traumatized by my first day there and felt shut down by my clinical instructor when I mentioned how intense that experience was. It didn’t get better. In fact my last day my clinical instructor pulled me into her office and said “I was this close to failing you.” Then proceeded to berate me. It was pretty awful. Aside from that one experience my grades were stellar, I graduated Magna Cum Laude, and I had glowing reviews from every other clinical instructor.

I think the instructor didn’t like me. I think I didn’t like maternity. And I think my first day on the unit having to deal with a dead baby and grieving mom by myself for nine hours straight with no support from the nurse or my instructor set the tone for me.

That entire experience left a bad taste in my mouth. Through the rest of my nursing career I steered clear of anything maternity based.

My first experience with post partum care after nursing school was years later on an inpatient psychiatric unit. I had my first patient with postpartum psychosis. I treated her the same as all my other patients and honestly didn’t think much of it. Psychosis is psychosis. Needed to be stabilized and discharged with a plan in place. I had a few pregnant patients inpatient and then a few more postpartum psychosis cases. Enough that I felt I had some exposure to perinatal and postpartum mental health care. I learned what medications are safe-ish for pregnancy and medications for post partum with a nursing mom. I can’t say I loved it. I just did it.

Then I started outpatient care. I was young (28?) and I think as a result I saw a lot of young female clients. I don’t remember the first one who told me she was pregnant. I do remember several different times though. Some were teenagers disclosing looking scared and ashamed. Some had abortions. Some didn’t. Some were young women who were newly married and glowing with excitement.

I do remember trying to convince the first two of my pregnant clients to see a different psychiatrist or APRN who has more of a specialty in peri-natal care. They asked who that would be. I asked the psychiatrist I worked with at the time who had far more experience than I did. He gave me two names. I gave them to my clients. One of them actually called. The other didn’t. They both came to their next follow ups and essentially told me they didn’t care that I didn’t have a specialty in peri-natal care that they trusted me. They liked me, and one of them said, “I’m sure you’ll figure it out for me.”

I remember going back to the old psychiatrist I worked with. I reviewed their meds with him. I talked to the pharmacist on staff at the hospital. And for the next few pregnant people I continued to seek regular supervision and took some continuing education courses specific to peri-natal and post-partum psychiatric care. Fast forward seven years.

Probably a third or more of the caseload of my entire practice is peri-natal and/or postpartum clients. I know the postpartum specialty therapists. They all refer to me for medication management. I get calls from OB-GYNs and therapists asking if I can fit in a post partum case. I never advertised this part of my practice as it developed. I think it’s all been word of mouth. There are very few psychiatric practitioners willing to treat pregnant women and even fewer who will take on acute postpartum cases. I honestly didn’t realize how hard it is to find a provider to treat pregnancy and post partum until I started doing it.

I carried my own biases into this part of practice back when I first started not just from my first bad experience in nursing school. I thought of postpartum illness like many probably think of it- as an illness where Mom’s don’t like their babies, and maybe even try and kill them. I had a case in the pediatric emergency department when I was two or three years in. I remember it was a five week old with a head injury. There was a clear handprint on the baby’s head.

It ended up having a skull fracture. The Mom sat stone faced. Blank. The dad looked like he wanted to puke. The baby just lay on the bed until I picked it up and cradled it when it cried. I remember glaring at the parents. Why are they just sitting there? Why would they hurt this beautiful baby? Eventually the Dad broke down and told us it was his wife who did it. She hadn’t been right since the birth. Looking back now I can recognize that she clearly was psychotic at the time, and she was ultimately transferred to the adult hospital and admitted for psychiatric evaluation. I think we knew that she had postpartum but I didn’t truly understand what that meant other than her being cold and her baby having skull fracture.

These were the experiences I brought with me into my career as mental health APRN. When that client told me to figure it out for her. I remember thinking, what the hell am I getting myself into?

At some point during the following few years I got pregnant and had my own kids. I did not experience postpartum. I experienced twins. Twins who required exclusive breastfeeding. I had a C-Section. I went blind (my vision came back). I had pre-eclampsia/eclampsia. All in all pretty shitty time. But I wanted those little dudes. I worked so damn hard to have them. I kept them in through 36 weeks and 3 days of puking daily often multiple times daily. I was sleep deprived. But I was so incredibly happy to have them. I remember staring at them. I should have slept. But I couldn’t look away. Post partum time sucked because I was sleep deprived, I was sore, I had twins, and I had to breastfeed. But I didn’t have any overwhelming depression or anxiety on top of it. For that I am grateful.

Now I’m seven years into outpatient work. I’ve had many, many, pregnant and postpartum patients. I’ve treated depression, anxiety, mild to moderate to severe. I’ve treated post partum psychosis and post partum anxiety and post partum mania. While I’m writing the diagnoses though I’m picturing the women.

Because the women touched me and taught me. I’ve treated women who have had severe post partum illness but still felt incredibly bonded to their babies. What I found more common is women feeling bonded to their babies versus not. The clients who feel not bonded are definitely less common. Some times the only relief for women with post partum depression and anxiety is the time with their baby.

The women who struggle with bonding tend to have significantly more guilt, more shame, and in my experience are higher risk to develop more severe symptoms. When I have some one come a year before they want to get pregnant I want to do a happy dance. I reassure them that 1. there are medications safe for pregnancy and 2. in my experience the clients who figure out the meds that work for them before pregnancy and before post partum do much better in the long run.

The clients I’ve treated during post partum; some of them I’ve now treated through two and three more pregnancies and two and three more post partum time periods. I’ve counseled women who had severe illness who want to get pregnant again. Such deep fear exists and also such hope and longing. I’ve never counseled against a pregnancy. I do review the data, and the pro’s/con’s, risks and benefits. I had one woman start crying and look at me, and ask me “If I do this I’m just scared you won’t treat me because I was so sick before and it took us so long to get me better. Please just promise you won’t stop treating me. I’m so sorry. I just want this so bad but I can’t do it without you.”

People who know me, know that I am not someone who cultivates dependence on me. If anything I do the opposite. I want people to be flying free and never feel that I was solely responsible for healing them. Because they do all the work. I’m more like the tour guide. They are the driver. But treating post partum illness has made me appreciate the provider-patient relationship in a way that I haven’t with any other types of clients or illnesses.

There is not another illness that makes women feel so raw, so vulnerable, so shamed, and isolated as perinatal and post partum does. Because pregnancy is supposed to be a happy fun time. To feel like you’re breaking inside is not socially acceptable. Because post partum is stressful, and you have a new baby, and people think maybe your overreacting and why are you so sad, just take a nap and it will be fine. Why are you sad? You have this beautiful newborn baby to love on?

This has all been said to me. “My life is perfect. This is what I wanted. Why do I want to die?”

I watched When the Bough Breaks on Amazon. It’s heartbreaking and incredibly accurate.

Everything leading up to my career in psychiatry made me think I would never have anything to do with pregnant women and post partum women. But honestly it’s one of the most rewarding aspects to my career and it’s a lifeline that my practice and the providers here have all embraced this as part of our mission.

I’ve held a lot of fears, a lot of pain, and a lot of those deep dark scary thoughts that are not voiced anywhere but my office.

I think back to the mom in the emergency department who broke her child’s skull (the baby was fine, as skull fractures go it was mild and no long term issues). I think of her so differently now. I see her as ill and clearly not engaged in treatment. I wish she had a provider who could have intervened sooner. Some one who could have hospitalized her sooner and medicated her sooner. I think back to that mom and I think she’s why I figured it out. Because somebody needed to. Because mental illness strikes pregnant women and postpartum women too. She needed treatment. Not judgement.

The best part about telehealth is intervening fast with post partum illness. I can see clients 3, 5, or 7 days post partum because we do the appointment remotely. But for my established clients we already have a plan. Usually I see their smiling face come on the screen at 3-4 weeks post partum. They’ve already restarted the med they stopped during pregnancy, or doubled the dose we decreased for the last few weeks before delivery, or whatever the plan was they did. They weren’t terrified of post partum because we had a plan. They still struggle at times and sometimes I still have to refer out for higher levels of care. But they have support and we know what works and what doesn’t.

I had one client call me from their hospital room because they were fighting with their nurse who was trying to give them their lower dose of the anti-depressant and she knew we were supposed to go back up immediately after delivery. The poor postpartum nurse had to deal with me and the postpartum Mom telling her this was non-negotiable. Increase the dose and if she can’t do it then get me on the phone with some one who can. With my client intermittently yelling the birth weight and that she was able to have a vaginal delivery, and I had to tell her to stop yelling I’d talk to her later, let me talk to the nurse.

I’ve been texted pictures of newborns and I’ve been texted pictures of positive tests. I’ve been mid-telehealth when a client got a call from her fertility doctor, asked me to stay on the line to hear the result with her, and was there for her positive test result. I got the call when that same mom went into pre-term labor and delivered early. I saw her weekly until the baby came home from the NICU more for reassurance than anything.

I’m grateful I’m not the one catching the baby. Because good lord that’s just disgusting. I’ve had to be there for a few childbirths including my own kids, and I’m all set. But I am this peripheral support through entire pregnancies, post partum, more pregnancy, and more post partum, and sometimes infertility thrown in the mix also. It’s a journey that is incredibly intimate and to be a trusted component is incredibly rewarding.

Post-partum illness has a mortality rate. Women with less supports, family history of mental illness, and a history of their own mental illness like anxiety or bipolar disorder are at higher risk for psychotic symptoms which increases risk for suicide or infanticide.

Ask Mom’s how they are doing. When I ask mom’s how they are doing. Really ask. Eye contact and everything. They usually have tears well in their eyes and say, “No one’s asked me that,” because it becomes all about the baby. Ask them. And don’t dismiss their sadness as fatigue. Don’t dismiss their fatigue as just due to having a newborn. Ask if they have talked to their doctor. Ask if they have a therapist or mental health provider. We as a society need to open up the dialogue. We as a society need to support new mom’s and dad’s better.

Telehealth needs to remain permanent. Just as there are set in stone follow ups for baby and Mom with pediatrician and OB-GYN there should be a set in stone follow up for a psychiatric professional to meet with every new mom at least once in the first four weeks of postpartum.

Mental health has to become part of the pre-natal, peri-natal, and postpartum dialogue in doctor’s offices and in our communities.

The statistics are that 1 in 7 women will have clinical post-partum illness. Roughly 600,000 women a year in the USA. Approximately 50% of women with postpartum illness develop symptoms during pregnancy. IT’S NOT JUST HORMONES!! That infuriates me when I hear that clients have been told they are just being hormonal while they are literally breaking inside. 1-2 women out of every 1000 will develop post partum psychosis. 10% of Post partum psychosis cases result in suicide or infanticide. Suicide is the seventh leading cause of death in the first year after giving birth.

Educate yourself. All my clients love to be Dr. Google. This is one area I encourage googling. There are personal accounts that are heart wrenching. The more you know the more you may be able to help a friend or family member during and after pregnancy. Know that these women are not just hormonal. They are suffering from a mental illness with a biologic basis. There is treatment. 80% of cases are remitted completely with medication and therapy.

I think back to my first day in maternity at the ripe age of 21. I think back to all the emergency department cases that were so messed up. I think of all the cases that could have been prevented if they had adequate treatment. I think of my clients and their struggles that are so raw and courageous.

Just like I never went looking for nursing, it sort of found me. I never went looking for maternal mental healthcare. But it sure found me and I’m not sorry it did.