I decided to finally look into getting blue ray blocking glasses. I’m not sure if that is even what they are called…the kind of glasses that are supposed to protect one’s eyes from the harmful light of the computer. Specifically if, like me, you stare at it for up to eight hours or more a day.

I did some google searches and looked at a few of the “best sites” to buy blue ray blocking glasses. Then I went to those sites and looked up a bunch of them. I even added some to my cart on one site.

Then I walked away.

Then I went back to the site.

Then I closed my iPad again.

Then today I looked on Amazon and added more to my cart.

Then I stopped.

I am many things but I am always honest with myself. I reflected on the pit in my stomach that seemed to set up camp whenever I pulled up one of these eyeglass websites. I reflected on the “virtual try on” experience that made me just extremely sad as I stared at my face with the fake lovely glasses resting on my nose.

Then I felt like Winnie the Pooh in that scene when he is pondering and tapping his big yellow paw on his head.

I had a cataract when I was 4. It was removed. I am legally blind in my right eye and have been for as long as I can remember. I wore a patch on one eye for 6 hours a day for a couple years of my life. I wore a contact in my right eye (the cataract/legally blind eye) since the surgery and glasses also for as long as I can remember up until 6th grade I believe. In 6th grade I was old enough for the contact in my left eye.

The glasses were thick frames. I remember my eyes often being hot and sticky from the patch and the glasses. I remember being made fun of many, many, times by other children.

I had this Ah hah! moment in remembering all of this. Duh. Of course my entire body revolted at the idea of glasses, even just glasses to protect my eyes, because I was having flashes of seeing my clients in glasses. I was having flashes of being incredibly vulnerable in front of clients. Clients who do not need to see me have a breakdown if they so much as mention the glasses.

I have glasses. I use them at night. Alone. After I take my contacts out right before I fall asleep if I want to watch TV for a little while. I don’t think even my closest friends have seen me in them.

It’s an odd thing to be 37, a Mom, a boss, a nurse, so many kick ass things, and still be completely gutted thinking about buying glasses. This is what it does to people though- bullying. It stays there. In the back of my mind, in a filing cabinet that I put away and locked up, but that creeped out slowly with enough of a trigger.

I remain undecided on the blue ray glasses. I write this feeling odd. Somewhat shamed? Even though I know rationally it’s not my shame to bear. It’s the shame of my peers who made me feel less than because of a vision deficit that I had no control over. I’ve known since age 4 what it feels like to be different. And I’ve never attributed that experience to any of my life decisions, but it shouldn’t come as a surprise that I have devoted my life to serving the underserved and the bullied and the misfits.

Because I was one. Who knows? Maybe I still am. But the difference now, is I know I’m in good company.

I’ve worked in many different aspects of healthcare so I have an understanding of what’s meant by “different level of care”. You probably understand it too but you may not have thought about it.

There are different levels of care for all illnesses and situations. You may understand it better from a medical perspective. Have you ever had a relative who broke a hip? Perhaps they went from their home to an emergency department; the ED triages who needs admission to the hospital and who can be managed acutely and sent home with perhaps more supports in place. From the ED the broken hip is admitted for surgery. Perhaps after surgery they are in the ICU for a day because their vitals are not stable yet. From the ICU they go to a medical/surgical floor. Then from there they are not quite ready to go home but too well for the hospital, so they are sent to a SNF (Skilled nursing facility aka nursing home/rehab). From SNF they are sent home with perhaps in home physical therapy and skilling nursing visits once a day. From there they are then deemed able to go to physical therapy outside of the house and follow up at an office with an orthopedist.

The point of this is to demonstrate the multiple levels of care we have for people suffering from injuries or illness. At any point in that example did you think “Now that this patient is going to outpatient PT they are clearly the worried well”?

No. You didn’t. Because they had a diagnosed injury, surgery, and recovery.

What about the asthmatic who sees their pulmonologist once a year unless they are sick at which time the pulmonologist sees them daily until their 02 sat drops and they are not improving with outpatient care. They send them to the ED. Luckily the ED stabilizes them with IV steroids and they are able to return home and avoid admission.

Again- when the asthmatic is well and seeing their pulmonologist once a year for maintenance visits did you think to yourself, “They don’t need a pulmonologist, they are just the worried well,”?

No. You didn’t. Because they had a diagnosed medical illness, treatment plan, and exacerbation of illness which required an ED visit.

Please explain to me why, when I treat clients at an outpatient level of care in private practice I am told that I treat the “worried well”? A few people have said it to me over the years, more probably think it, but they know I will ask pointed uncomfortable questions and give a lecture on the stigma of mental healthcare.

Mental illness is the ONLY area of our healthcare where people who seek outpatient maintenance treatment are labeled the “Worried well”. Do cardiology patients have to deal with that bullshit? No. Their patient may never be hospitalized. They may never enter an emergency department. They may see their cardiologist once a year for their EKG, Echo, stress test, and renewal of their anti-hypertensives but they are never referred to as the “worried well”.

I’m about to get on my soapbox, in fact I think I’m already there. (But just so you have the mental image: imagine me standing left hand on hip, right hand waving around sometimes pointing and shaking sometimes running through my frizzy crazy hair looking passionate enough that you want to follow me into battle.)

People who seek outpatient psychiatric treatment are many things but they ARE. NOT. THE. WORRIED. WELL.

They are brave. They are survivors. They are people with diagnosed and treatable illnesses that originate in their brains.

They have Major Depressive Disorder Recurrent Moderate without Psychotic features (F33.2). They have Bipolar Disorder (F31.9) They have Postpartum Anxiety/Depression/Psychosis (There are a few codes for this- look it up). They have Generalized Anxiety Disorder (F41.1).They have Post Traumatic Stress Disorder (F43.10). They have Adjustment Disorders (F43.20-F43.24). They have Gender Dysphoria (F64.9). They have Dysthymia (cycling/irritable depression often co-morbid with trauma responds well to Lamotrigine now labeled as Cyclothymia F34.1). They have OCD (Not a billable dx any longer). They have Autism (Anthem BCBS says this is NOT a billable diagnosis. Add it to the list as to why I despise them F84.0).

These are a smattering of the diagnoses I treat on a day to day basis. We have over six hundred clients at my practice and six clinicians. Over six hundred people. But yeah they are totally all the “worried well”. I want to scream when I hear this. Because let me tell you maybe three of them are well enough to go a year without seeing me. A small percentage see me a minimum of every 3-6 months and the rest see me monthly, bi-monthly, and during acute crises weekly or more.

Private practice is the least acute setting. That doesn’t mean we see the least acute patients. And even if we do see the “least acute” that doesn’t make them the worried well. Are all the outpatient patients of every specialty- pulmonology, allergists, immunology, rheumatology, cardiology, endocrinology, etc.- the “worried well”? No. Most of them have moderate sometimes severe illness but they see skilled clinicians who work their butts off to keep them out of the hospital. Even then, some patients will end up hospitalized. Some will die. This is the nature of medicine. Psychiatry is no different.

We work hard to keep our patients out of the hospital, out of intensive outpatient programs, but we recognize when it’s out of our arena and they’ve reached a level of illness that requires a higher level of care.

Calling my clients the “worried well” infuriates me at a visceral level. Because I’ve seen their tears- even wiped them in some cases. I’ve encouraged them, listened to them, adjusted medications, changed medications, initiated, discontinued, met with families, done therapy, done visits in the parking lot for the autistic client who is too agitated to come inside, told them to put their knife away because even with a knife I’m not prescribing Xanax, tried to reason with psychotic people to take their anti-psychotic medication, watched as mania destroyed lives and supported through the first year after a manic episode while we stabilize, manage side effects of medications, and try to pull them out of the deep suicidal depression that follows the epic and destructive mania. I’ve treated during pregnancies that were planned, unplanned, and the result of rape. I’ve treated people postpartum and post-abortions and post-rape.

To call my clients the “worried well” insults them. Insults their illnesses. Insults their journey. Insults their ability to drag themselves into psychiatric treatment when our society and often their family members tell them that they are the damn “worried well” and to just do yoga and they will feel better.

Patients who seek psychiatric treatment and make it to maintenance treatment are not the worried well. They are healing. If they make it there without being hospitalized and without an IOP and they stay there until we get them off medication and they never need it again…they aren’t the worried well. They are lucky. Lucky we found the right medication the first try. Lucky they had a robust response. Lucky they found a good therapist who they engaged with weekly sometimes twice weekly for two years so they could work through all the despair they brought into treatment. They are lucky to live without a relapse in symptoms through acute future stressors. Those patients are rare. In fact I cannot think of one. Because mental illness IS. AN. ILLNESS. Maintenance is the goal. But there is always a risk of relapse and for women it is particularly risky if they have their illness controlled before having children- because having children is a risk for relapse or worsening of symptoms.

People who mention the “worried well” in regards to private practice in mental health brings to mind the term “toxic positivity”. It is always said with a smirk. It is discounting of every person’s journey into mental health treatment. It also discounts the skill of private practice clinicians who keep so many out of higher levels of care through finesse, clinical acumen, long term bonds and trust with patients, and generally being damn good at what we do.

Now you know. Never say this about mental health practices or patients. It is demeaning, inaccurate, and rude.

Sit with that discomfort. Process your emotions. It will help build resilience if you process negative emotions instead of ignore them or sublimate them. (Google toxic positivity). It’s not my job to take away the discomfort with a witty or heartfelt wrap-up. I want you to sit with the discomfort as I have. Examine it. Learn from it.

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.