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Navigating the postpartum time—or the time just after you’ve given birth—can be an emotional roller coaster. After giving birth, not only are you dealing with physical changes, but you may also experience changes to your mental health, such as postpartum depression or postpartum anxiety. Ob/Gyn Dr. Erica Newlin discusses what mental health changes new parents might go through before and after giving birth, and the best ways to navigate this time.

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Postpartum Mental Health Concerns with Erica Newlin, MD

Podcast Transcript

Speaker 1: There's so much health advice out there. Lots of different voices and opinions. But who can you trust? Trust the experts, the world's brightest medical minds, our very own Cleveland Clinic experts. We ask them tough, intimate health questions so you get the answers you need. This is the Health Essentials Podcast, brought to you by Cleveland Clinic and Cleveland Clinic Children's. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.

Annie Zaleski: Hello, and thank you for joining us for this episode of the Health Essentials Podcast. I'm your host, Annie Zaleski. And today we're talking about postpartum mental health concerns with obstetrician and gynecologist, Dr. Erica Newlin.

Having a child can be one of the most joyous experiences of your life. At the same time, navigating the postpartum time, or the time just after you've given birth, can present challenges. Not only has your physical self changed in the past year, but many people also experience mental health concerns, such as postpartum depression or postpartum anxiety.

Knowing what to expect from the postpartum period can help prepare you to develop any solutions to any concerns you might have that arise. Dr. Newlin is here to discuss the emotional side of postpartum concerns, including postpartum depression and postpartum anxiety, and how you can navigate through them. Dr. Newlin, thank you so much for being here.

Dr. Erica Newlin: Yeah, thanks for having me.

Annie Zaleski: So, we're here to talk about the emotional side of postpartum concerns today. So, how common is it that people might face mental health challenges or concerns after giving birth?

Dr. Erica Newlin: Peripartum and postpartum anxiety and depression, and just mental health concerns in general, are super, super common. Most studies really cite a prevalence of around 10%. But we think that that might be vastly under reported, because a lot of women just aren't seeking care or are embarrassed to talk about it.

Annie Zaleski: What factors contribute to this then? I mean, obviously there are so many hormonal changes going on and physical changes. Does that inform why they are so prevalent?

Dr. Erica Newlin: Definitely. There's just the stress of bringing a new life into the world. There's the lack of sleep on top of things. There are changes to your routine, maybe changes to your relationship. For some women, it can even be a big life adjustment as their new role of a mother, looking at their sense of identity. Some women and their partners may also be experiencing birth trauma from their deliveries.

There can be an expectation of how motherhood will be. And sometimes if reality doesn't always match expectations, that can be a contributor as well. Anecdotally, I feel like there's recently been an increase in postpartum depression with COVID-19 restrictions, since a lot of women feel very isolated and don't have those same social networks that they may have before. So there can be a lot of reasons and a lot of contributing factors.

Annie Zaleski: That's reassuring that there's so many different reasons that can go into it almost, in a sense, because then it's like, OK, if you're feeling one way, it's completely valid and completely justifiable.

Dr. Erica Newlin: And I think some of the issue with postpartum depression and anxiety is women feel guilty for feeling the way that they feel because we're told that this is a time of joy and happiness. And if you're not feeling that way 100% of the time, then you're starting to feel guilty, and that can be a very large contributor as well.

Annie Zaleski: Postpartum depression, I think, is one notable condition that a lot of people are very familiar with. And so, what causes this?

Dr. Erica Newlin: We're not quite sure why some women have postpartum depression and some don't. There are certainly some factors that put women at a higher risk for postpartum depression. If you have a history of depression outside of pregnancy, if you've had postpartum depression after a previous delivery, that can put you at a higher risk. There's thought to be some genetic component, as well. And there's also thought to be a contributing factor of hormones, too, since there are large hormonal changes happening right after delivery that can certainly be contributors.

Annie Zaleski: So is postpartum depression different from other types of depression? And if so, how? And can it be something where maybe if you've been diagnosed with a specific type of depression, you could also get diagnosed with postpartum depression?

Dr. Erica Newlin: The biggest difference between postpartum depression and depression outside of pregnancy is just that time period. So, we think about postpartum depression being within that first year after delivery, and resolving over that first year. The diagnostic criteria and the diagnosis that we use are very similar between depression outside of the perinatal period and the just postpartum depression. So diagnostically, the experience of depression is the same across both postpartum depression and, I don't want to call it regular depression, but you know what I mean. Yeah.

Annie Zaleski: People might have also heard the term, the “baby blues,” or the postpartum blues. What are the differences between that and postpartum depression?

Dr. Erica Newlin: The biggest difference comes down to severity and length of time. Baby blues tends to peak in that first week after delivery and resolve in those first two weeks. It's really common to feel teary or to feel sad, and just not really know why.

But if you find you're no longer able to take joy in the things that you used to, or you're feeling worthless, or hopeless, or if it's affecting your ability to care for your baby or to care for yourself — say you can't get out of bed in the morning, or you're not able to eat, or you're eating too much — those can all be more depression than the baby blues.

Annie Zaleski: Why do people develop the baby blues then, and what causes that?

Dr. Erica Newlin: Yeah. So that's often thought to be hormonal changes as well. And they're very, very common. The statistics that's usually cited are around 70% to 80% of women have some sort of feeling of sadness or teariness after delivery. And that can be really normal, and also not something that women expect to feel. It can be affected by lack of sleep, stress, as we mentioned, and hormonal changes. So if you're feeling that way, know that you are not alone and that it is very, very common.

Annie Zaleski: I think you're right. People might be expecting, "I've finally given birth. I'm so excited. I have a child." And that should be the happiest time of your life. But so, to be feeling sad or teary, people might be like, "What is going on?"

Dr. Erica Newlin: And it may not even be an inciting event. You may just find that you're... A lot of women report that they have a heightened emotionality during pregnancy. And they're always like, "I was watching this commercial and I just started crying for no reason." Sometimes that can be even more heightened right after delivery. And just, as I mentioned before, give yourself grace. It's not that there's anything wrong with you. It's just part of that process of recovery.

Annie Zaleski: So you mentioned a few symptoms of where the baby blues have gone into postpartum depression. What are some other signs, or warning signs, or symptoms that people should be on the lookout for, for postpartum depression?

Dr. Erica Newlin: I think if your symptoms are persisting past those first couple weeks, and if you feel like things aren't getting better, that's another reason to call. Or if things are escalating. And if you feel like, again, it's really affecting your ability to care for yourself or to care for your baby.

And some of the markers that really differentiate baby blues as opposed to depression is not being able to feel joy or feeling worthless. Very much internalizing those feelings of hopelessness, and worthlessness, and not being able to enjoy anything about that postpartum period. That is more consistent with depression than baby blues, and is definitely a reason to reach out. Because it's not a reason to feel embarrassed, because we really want to be there to help, and to intervene, and to get you through this time.

Annie Zaleski: So another, I think, serious mental health condition people can face is postpartum psychosis. What is this and how does this differ from postpartum depression?

Dr. Erica Newlin: Yeah. Postpartum psychosis is usually associated with delusions. Those are thoughts of things that aren't true, or hallucinations. And those can be that you are seeing things that aren't there, or are hearing voices or sounds of things that aren't there. We commonly think of command hallucinations, where you're hearing voices telling you to do things.

The reassuring thing though is that postpartum psychosis is thankfully rare. Certainly if you are experiencing those things, that would be a reason to seek care right away. We don't see it commonly, so I think it's something that you should mention right away to your physician.

Annie Zaleski: Do doctors know why some people might develop that?

Dr. Erica Newlin: Certainly if you have any underlying mental health challenges during pregnancy or prior to pregnancy, that can put you at higher risk. And similarly to postpartum depression or postpartum anxiety, it can be sparked by things like severe lack of sleep, stressors in your life. Those can be contributing factors as well.

Annie Zaleski: I want to talk a little bit about postpartum anxiety, because that's come up. And what does that look like? And when do you know when normal worrying about taking care of your child turns into something maybe a little bit more intense and a little bit more complicated?

Dr. Erica Newlin: I'm glad that you ask, because I feel like postpartum anxiety doesn't get as much attention often as postpartum depression, but can be just as common. So on the normal spectrum of things, I hear from a lot of women that they have a constant worry over things in the first couple of weeks. And it's almost like Mother Nature gave us this hypervigilance in caring for our baby to where we're seeing dangers everywhere. It's almost like everywhere has turned into the set of a Final Destination movie or just thinking about the bad things that could happen. And in some ways, that can be normal.

After I had my son, even as a physician, one of my most common Googling in the middle of the night was, “is it normal if?” You're often like, “is it normal if this?” Because you're just worried about many things in those first couple weeks. And that can be very common because it's just very much a time of transition.

But if you find that you're having what I call perseverating thoughts — like if you can't move past that worry, if the worry is keeping you from living your life, or if you're constantly worried about something happening to you or something happening to the baby, or it's affecting your sleep or ability to function — that's not on the normal side of things. And that would be a reason to seek care.

Annie Zaleski: When might this develop then? Does it develop in a certain amount of time after you give birth? Can you start to feel this before you even give birth, maybe in the last couple months of pregnancy?

Dr. Erica Newlin: Certainly. Both postpartum depression and postpartum anxiety aren't really restricted to that postpartum period. So you can start to experience it any time during the pregnancy and in that first year after delivering.

So I often open up a conversation even at that first Ob/Gyn visit. What is your mental health history? Do you have any concerns about depression or concerns about anxiety? So we can keep revisiting that during the pregnancy to see if there's a reason to provide some interventions or to be concerned.

Annie Zaleski: I think that's a really good point, because I think a lot of people might not realize that all of these things they're feeling might start before they even give birth. I would imagine that could be disorienting if you're feeling a certain way, maybe in the last trimester, and you're just not sure what's going on.

Dr. Erica Newlin: Right. And there can be a heightened feeling after delivery. So we usually see it in that first month after delivery for postpartum depression. So around 54% of women are diagnosed in that first month, and then around 40% in that month two through four. So it's rare after that month five, but still certainly something to consider in that whole first year.

Annie Zaleski: What are some other common emotional changes that people might experience postpartum?

Dr. Erica Newlin: I do hear often that people feel angry and they're not sure why. It's very common to feel rage towards your spouse, or rage towards any partner or caregiver. Or that feeling that only you're able to do things the right way. That's something that can be very common, because there are big emotional changes and changes to your relationship after you have a new baby. So having a little bit of conflict with your partner sometimes can be normal, and something to expect and discuss with your partner after delivery.

Annie Zaleski: I think that's also something people might not expect because, I mean, and obviously, probably new parents aren't sleeping as much. So there can definitely be a little bit of tension there. But you might be like, "Why am I so angry? Why am I being set off by something very small?" That can be also disorienting.

Dr. Erica Newlin: Yeah. I hear a lot from women that they're like, "I'm mad at my partner and I don't know why." And it's sometimes you just, again, giving yourself grace, and knowing that the immediate postpartum period doesn't last forever. One day the baby will sleep through the night. And you're all just trying to get through this period can be helpful. And just knowing that other women are going through the same thing and you're not alone in these periods.

Annie Zaleski: And I think that's very true, because you might also think, "I am the only one feeling this way. This is so strange. What is going on?" And that could also be just scary, honestly.

Dr. Erica Newlin: Right. Definitely. And as I mentioned, there's a lot of expectation in the media and we put a lot of pressure on ourselves for this postpartum period to be a time when you have a rosy glow, and you're a new mom, and everything is great, and you feel so mothering.

But it's also a huge time of adjustment. You're healing, potentially, from a major surgery or a difficult birth. And you're going through both physical and mental healing, and have large demands on your time. And it's a big change. So it's very common to have differing emotions through the day.

Annie Zaleski: The idea that I think more people now are seeing the connection between your physical health and your mental health. And I think that's a really good point that, hey, be good to yourself. You just went through something very, very major from a physical sense. It makes a lot of sense why your mental health might also be affected.

Dr. Erica Newlin: Definitely. And as I mentioned before, I think women have been more isolated recently with COVID. It's changed our social networks a lot. So some women don't have those same safety nets as before. Family isn't visiting as regularly due to certain concerns, or we're not visiting friends. Not as many people are coming to see the baby if you're worried about the baby getting an infection. So it can feel very much like you're alone sometimes.

Annie Zaleski: So how do you get diagnosed with postpartum depression, or postpartum anxiety, or something else then? Do doctors have a test, or how does that work?

Dr. Erica Newlin: So there are... If you call with symptoms, there are certain questionnaires or diagnostic criteria that we use. But ultimately it's about how you're feeling. So I think it's worth having a discussion on how much is how you're feeling impacting your life? And that's worthwhile to talk about with your doctor. Because I think these questionnaires and these tools are great as an initial scoring as an initial triage, but it's also a more nuanced discussion sometimes.

Annie Zaleski: Well, that's what I was going to ask is that, is it ever a case where if someone calls their doctor and says, "I think I have postpartum depression," but they might go through a diagnostic test or a conversation, and their doctor might say, "Actually, I think there's something going on that's not related to the postpartum period."

Dr. Erica Newlin: Right. I think that certainly we have certain questionnaires and things like that. But if it's something outside of those questionnaires, then it's definitely worth talking about and may lead to different roads. Even sometimes with depression, or sleep, or appetite, there may even be things outside of mental health, because sometimes things like thyroid issues can lead to mood changes as well. So it's always worth a discussion with on how you're feeling, and never a silly or embarrassing reason to call.

Annie Zaleski: So if you are feeling, obviously that sometimes if you're like, "OK, I need to do something about this. I can't keep having the same symptoms impacting my life," what are some treatment options available? What's found to be effective?

Dr. Erica Newlin: Often my first line is, we have quite an extensive list of counselors and support groups. There are national postpartum support groups that provide both virtual outlets, as well as organizing things like stroller walks or get-togethers that may help. Just talking with women that are going through the same thing and validating these feelings that you're having for some women is enough.

Some women sometimes may need treatment. So we'll consider, often we use a classification of medication called SSRIs, that's selective serotonin reuptake inhibitors, which is most commonly people have heard of as trade names like Prozac™ or Zoloft™. Those are often our first line since they're safe with breastfeeding and can work very well for people.

And I think sometimes women have heard different things about antidepressants or carry a stigma about antidepressants. But usually I tell women that this is so common. And if your experience is impacting your life, then it's worth consideration of taking medication.

Annie Zaleski: Well, and that's what I was going to ask. So I would imagine a lot of people might be concerned if they are breastfeeding, about what they can take and can't take. And that could be a consideration for some people.

Dr. Erica Newlin: And I think some studies have shown very mild side effects. But the way I often describe it with patients is, if you think about how much your depression or your anxiety is affecting your ability to mother, any possible small side effects from breastfeeding and antidepressants would be minimal compared to what you're experiencing on a day-to-day basis. So if there's something that can help you, then it's definitely worth exploring treatment.

Annie Zaleski: And that's a really good way of looking at it too, because it centers the baby a little bit more, and it helps. Because I'm sure a lot of people also might be worried about that. They might be like, "I'm having such a hard time. I want to make sure that I'm taking care of my child in a good way." And that can also potentially make things worse.

Dr. Erica Newlin: Yeah, definitely.

Annie Zaleski: So we've talked a little bit about this, but in general during the postpartum time, what's normal, and when should people really start to worry?

Dr. Erica Newlin: The baby blues and that initial teariness, sadness after delivery can be surprising in its intensity, but that is short lived. And if you find that something is lasting past that first week, or if you find that it's affecting your appetite and your ability to function. And really if you're internalizing that feeling of worthlessness or hopelessness and not getting joy, or if you find that you're worried about something to the point where it's affecting your sleep or having these racing thoughts, those aren't normal and definitely a reason to reach out to us.

Annie Zaleski: And it sounds like being very proactive about this too, and really staying on top of this is also a really good method of trying to nip things in the bud, I guess, in a sense.

Dr. Erica Newlin: Definitely. Because as I mentioned, I think a lot of women suffer in silence because they are worried about being judged or they're worried that they really shouldn't be feeling these feelings. And I think a good bottom line is, it's not your fault. It's not that you're a bad mom. It's not that you don't love your baby. No one is going to think any of those things. And it's really worth seeking care because there are things that we can do to help. And we're not here to judge you. We really want to help.

Annie Zaleski: How soon after seeking treatment and reaching out to a doctor might people see results?

Dr. Erica Newlin: Sometimes it does take a little time, especially when starting antidepressant treatment. Some women do report they right away feel better. But usually we're thinking it takes around four to six weeks for it to reach its full effect.

Annie Zaleski: If someone decides to go to counseling, how soon might that help then? Does it vary from person to person?

Dr. Erica Newlin: That can really vary. As I mentioned, for some women, it can be almost an immediate relief. Especially with some of the support groups, I've had some women come back for their next visit and they're just like, "Oh, man, I just didn't realize that so many women are going through the same thing. It was just so validating and so rewarding to hear from people who were having the same experience I was."

And there's almost a sense of catharsis because they feel so much better to know that they're not alone. Sometimes when we're talking about counseling, or doing the work, or therapy, that can certainly take more time. But I think many women do feel relief very quickly once they start to seek care.

Annie Zaleski: I think that's really powerful is that, once people maybe have someone else to talk to who's a peer and they can be reassured that what they're feeling is totally normal. That can be so powerful.

Dr. Erica Newlin: Definitely. I hear that a lot.

Annie Zaleski: Are there any good questions to ask your doctor about the postpartum time that we maybe haven't talked about, or any different angles that you hear a lot?

Dr. Erica Newlin: I've mentioned a lot. I think any feelings of anger, stress, sadness may be normal. But if you're ever worried that they're not, certainly don't hesitate to bring it up with your doctor. Because as I mentioned, we're not here to judge and really want to help get you in touch with resources. So certainly don't hesitate to bring something up if you're worried.

Annie Zaleski: Well, is there anything else you want to add then about postpartum concerns and mental health challenges that we haven't talked about?

Dr. Erica Newlin: I'm happy that there's been more discussion about these things. I've seen a lot of outreach on social media and a lot of women talking about their experience. So, my hope is that since more people are talking about it, more women will be open to bringing that up and getting help.

Annie Zaleski: Absolutely. Something that's almost normalized talking about it and saying, this is about as normal after giving birth as maybe having different physical challenges. So, it makes a lot of sense.

Dr. Erica Newlin: I want people to feel as comfortable bringing that up as they do bringing up their other issues, and to not see it as anything that carries a stigma.

Annie Zaleski: Thank you so much for this conversation, Dr. Newlin, and thank you so much for being here. This has been really, really great. I think really helpful.

Dr. Erica Newlin: Yeah. Thanks so much for having me.

Annie Zaleski: If you have postpartum concerns, your doctor can help you figure out the best next steps. Visit clevelandclinic.org/womenshealth, or call the Women's Health Institute at (216) 444-6601 for an appointment.

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