Motherhood & Mental Health

Podcast Transcript

Dr. Erica Newlin:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things reproductive health. I'm your host, Dr. Erica Newlin. This podcast is intended to help you better understand your health, leaving you feeling empowered to live your best. On each episode, you'll hear from our experts on topics such as pregnancy, fertility, menopause, and everything in between.

On today's episode, we're talking about mental health during pregnancy and postpartum. Many women experience emotional changes during pregnancy or after delivery, but often feel unsure what's normal and what might be a sign to reach out for support. I'm joined by Dr. Lulu Zhao, co-director of Women's Behavioral Health, to discuss signs, risk factors, and support strategies so women and families feel less alone and more empowered. Thank you so much for joining me on the podcast, Dr. Zhao.

Dr. Lulu Zhao:

It is a pleasure to be here, Erica.

Dr. Erica Newlin:

Before we start, can you tell our listeners a little bit about your role in the Cleveland Clinic and your background?

Dr. Lulu Zhao:

Would love to. So I am the co-director for Women's Behavioral Health here at Cleveland Clinic. I am a board certified Ob/Gyn who completed a fellowship in women's mental health after my residency in obstetrics and gynecology. I guess I always knew at that point that I wanted mental health to be part of my career. Later on, just kind of related to the nature of my work in mental health, I also became board certified in addiction medicine. And so my role at Cleveland Clinic is to make sure that women during their entire reproductive life course have access to good mental health care when they need it.

Dr. Erica Newlin:

Fantastic. Let's begin with an understanding of mental health. During these time periods of pregnancy and postpartum, what are the most common emotional or mental health changes people experience during the pregnancy and postpartum period?

Dr. Lulu Zhao:

Being pregnant and then becoming a parent is such a transformative experience. So there are a lot of emotional changes that come along with that. On a neurological level, our brain actually changes during pregnancy so that we activate our circuits for forming attachments and relationships, our anxiety circuits, and our reward circuits so that we can become better parents. You want to be able to listen to that baby's cries and feel a need to protect them, or you want to be able to look at your baby's face and feel that need to really love them and take care of them. So because our brain is going through all these changes and our lives are going through all these changes, it's very common for people to have really big emotional changes in the postpartum period as well. And so very commonly people do get some degree of mood volatility in the immediate postpartum period.

Dr. Lulu Zhao:

This is kind of the underlying basis for what we call the postpartum baby blues. When just looking at your kid and you just want to cry because you love them so much and you wouldn't normally react in that way. But that postpartum period would also be a time of more scary emotions. So a lot of people do experience anxiety in the postpartum period because there is a lot of new things and the baby is very precious to you and you want to make sure that you're doing the right thing. And so anxiety is highly common in the postpartum period. And then a significant portion of women can also feel depressed during the postpartum period, which is obviously not what they're expecting or hoping to feel when they first become a parent.

Dr. Erica Newlin:

How can someone differentiate between those normal baby blues and postpartum depression?

Dr. Lulu Zhao:

The main differentiator is how long these kind of unusual feelings last. So postpartum blues is classically a very transient period of heightened emotional volatility and it usually isn't supposed to last more than two weeks. And it's not all negative feelings either. Like I said, it could be that you're watching a commercial and you're just bursting into tears. That is postpartum baby blues. But what becomes postpartum depression is that those two weeks have passed, your emotions are not only more, I guess, intense than what you're used to feeling, but they have a negative bias to them, right? You tend to feel less happy or you are feeling more negative about your parenting abilities. You are anxious as opposed to just protective. When it becomes sort of that longer term, again, more negative set of feelings and it's starting to cause impairment, that's going to be depression.

Dr. Erica Newlin:

Now that we've laid the groundwork for understanding perinatal mental health, let's explore how physical recovery after birth can influence emotional wellbeing. How does physical recovery affect that emotional or mental wellbeing?

Dr. Lulu Zhao:

A lot of the patients I see in my practice have suffered things like birth injuries or a bad tear or they're just having a lot of pain. And that certainly increases the risk for developing a postpartum mood disorder. There's probably a 1.5 to 2.5 increased risk of developing a mood disorder if you also are suffering from a chronic pain type of condition. And so for women who have had a difficult birth or they have other medical issues during the postpartum period, it's important to take care of your physical health as well in addition to your mental health because the two will go together hand in hand.

Dr. Erica Newlin:

Can you talk a little bit about sleep and how sleep contributes to recovery?

Dr. Lulu Zhao:

So sleep is such a vital need for our brains. And unfortunately when you become a parent to a newborn, you're not getting a lot of sleep. And so if you are somebody who is chronically sleep deprived, you're going on three days without having decent sleep, your risk for developing emotional volatility is be really high, and then your risk of developing an actual mood disorder is also going to be increased. So as somebody who treats women for postpartum mental health disorders, if someone describes to me that they're not sleeping, that they are so anxious that they just stay up all night staring at their baby, one of the first things you try and correct for is sleep because the other important thing to think about when it comes to depression is severe sleep deprivation is also an acute risk factor for suicidal ideation. And so it's very important to be mindful of sleep.

Dr. Lulu Zhao:

I encourage my pregnant patients before they deliver to think about how are you going to protect your sleep? Are you going to set up block schedules with somebody else in the household? Are you going to choose to provide bottles of pumped milk, donor milk formula? I tell my patients, you need to get at least one decent night of sleep, which I would define as realistically four to five hours in a row, at least every three days.

Dr. Erica Newlin:

You've alluded to it. You get this hypervigilance sometimes after you deliver that is a mother nature gift. But then that can feed into definitely not being able to sleep.

Dr. Lulu Zhao:

I see a lot of moms, and I felt this way too when I had my kids, you're kind of hyped up when you first have your baby. And when they're asleep, you want to just be doing everything, doing the laundry, looking at them, texting your friends, but they don't sleep that long. So you have to be really mindful that you are paying attention to your need to sleep.

Dr. Erica Newlin:

What about body changes after birth? How does body image tie into postpartum mental health?

Dr. Lulu Zhao:

There's so many physical changes after you have a baby. And I think social media does a disservice to us and making us think that it is realistic for the majority of women to just bounce back. And I would say that is not true for the vast majority of women. It takes time to restore your body to the way it was. And sometimes it will never be the way that it was because you just brought forth new life in the world. But for people who have a strong attachment to body image, or especially if you have any kind of body dysmorphia, the changes that happen to your body during pregnancy can be severely dysphoric and can cause a lot of mood symptoms. So I think it's good to be aware if you are somebody who maybe has certain expectations for your body. I think it's really important to reality check that a little bit and then to give yourself some grace.

And that might require therapy for people who really struggle with body image, to work with a professional who can help you figure out a way to embrace the changes that your body has gone through and to accept them.

Dr. Erica Newlin:

What are healthy expectations as the body heals?

Dr. Lulu Zhao:

So I think healthy expectations would be that you are making forward progress in terms of your ability to perform physical tasks and your ability to kind of look more the way that you looked before pregnant. But I also think that has to be interpreted in the context of your resources, right? If you are somebody who now you're juggling three kids and you don't really have spare time for yourself and you don't have time to exercise, you're going to have a little bit of a slower progression to your ideal body weight or your ideal level of fitness. And you have to accept that that is your reality sometimes. I guess on the other hand though, if you had a delivery and you are still in excruciating pain weeks later, that to me would indicate as an Ob/Gyn that there are unmet needs here, that maybe you need to go to physical therapy.

Maybe you don't have a properly healed tear somewhere, because the pain should be getting better. I would say for most of my patients, if by the six week postpartum visit, if you're not kind of feeling like you can drive a car, you can play with your children, you could sit and walk around, that would indicate there's some more work to be done here and there are resources for that.

Dr. Erica Newlin:

We’ve had our pelvic floor physical therapist on before and they are such a great resource. I wish it was standard of care for everyone to go.

Dr. Lulu Zhao:

Agreed. Because your core is weakened, there is a lot of back pain, you're hunched over all the time. A lot of people get wrist tendonitis from holding the baby and breastfeeding. You don't have to live with that kind of pain. There's treatments for that.

Dr. Erica Newlin:

Obviously there's a lot happening physically and emotionally after birth. And for some, this might be the farthest thing from their mind, but what about postpartum sex?

Dr. Lulu Zhao:

Postpartum sex. So I think the statistic is something like most women don't want to have sex until they're about three months postpartum. Sex is an important part of relationships. I do truly believe that. And so it can be hard to negotiate sometimes with partners, the fact that your body has changed, your priorities have changed, and your schedules have changed. So sex does fall a little bit by the wayside. I do think as a couple, if you are not engaged at sex at all after three months postpartum, that might be a sign that you have unmet needs too, right? You have no time to bond with your partner. You maybe are not physically feeling well enough to have intercourse. And I think that is something that you might want to bring up to your Ob/Gyn like, "Hey, is this normal? I don't feel like having sex or I don't feel like I'm comfortably have sex."

Dr. Erica Newlin:

I would add too, I tell a lot of my patients that things might feel different, but it shouldn't hurt. And if there's pain, then again, to reiterate, that's something that I want to know as a gynecologist and something that we can help with. Breastfeeding can lead to vaginal dryness and that's not something that we talk about very often. But we have ways to help with that too.

Dr. Lulu Zhao:

To me, the sex piece brings up the fact that one of the biggest changes that families go through when they have children is that you go from a dyad of you and your partner to the family unit and so many parents kind of lose the dyadic relationship once they become a family. And I do think that in terms of mental health, it's important to maintain that relationship with your partner because otherwise you're kind of just like coworkers taking care of a kid. And I think the desire to have sex reflects in some way a healthiness in that relationship that you know each other as individuals still, that you're having some one-on-one time together. And again, I think if you never want to have sex with your partner anymore, maybe that means that you don't really have enough time for self-care and to get to be with your partner.

Dr. Erica Newlin:

For sure. And there are, again, a lot of resources and counselors here at the clinic. We have sex therapy and just definitely self-exploration.

Dr. Lulu Zhao:

Yes, exactly. Your sexual relationship does oftentimes change after children.

Dr. Erica Newlin:

With all of these changes happening at once, physical, emotional, hormonal, plus adjusting to life with a newborn, it may be easy to brush off your emotions as simply feeling overwhelmed. Let's talk a little more about how someone can tell when it's time to reach out for help. What are early signs of postpartum depression or anxiety that women and families should watch for?

Dr. Lulu Zhao:

That's such a great question because I think especially when you have your first kid, you have no idea what is normal to feel versus not. So what I would describe to my patients is that obviously your day is going to feel a little bit more hectic when you have a child, but if you were to start feeling withdrawn from activities that you normally like, so for example, your mother says, "Hey, let's go out to lunch." And you just feel like, "No way, I can't do that. That's going to be too difficult." A lot of what if, what if this ... What if the baby poops when I don't have the spare clothes? What if there's a car accident? If you're having a lot of what ifs that's preventing you from doing normal activities that you would normally enjoy, that can be a red flag. I also see a lot of relationships get strained as people suffer from depression, anxiety, right?

Because when you're depressed or anxious, you have much lower tolerance for interpersonal stress. So if you find that you are blocking people on your phone or putting your phone on do not disturb a lot, or you don't want to talk to your family members. There's a lot of arguments that seem like they're over nothing. That might be a sign that you aren't doing as well mentally as you could be, because something is not teaming there in your village, right? And that could be a sign that either your village truly isn't there, or maybe you have a bit of a negative cognitive bias because you are feeling depressed or anxious. Other things that I tell patients to look out for is if you are not sleeping, it isn't normal to feel like you can not sleep for days on end, especially if you're so anxious that you can't fall asleep, you lay in bed and your mind's just going a million miles a minute, or you wake up at night in a panic and you can't fall back asleep.

That's not really a normal thing. And that could be a sign that you have postpartum depression or anxiety. The obvious symptoms of, “I'm crying all the time,” “I'm suicidal.” Yes, those would be huge red flags, but I do think a lot of times it is much more subtle than that. It's this general sense of discontent that things are not easy, that you're struggling.

Dr. Erica Newlin:

It is normal to feel overwhelmed sometimes, but not all of the time. And you alluded to this with particularly if someone's feeling suicidal or crying all the time, but are there other symptoms or experiences that should prompt someone to seek professional help right away?

Dr. Lulu Zhao:

So there's true psychiatric emergencies in the postpartum period. So for example, postpartum psychosis, which isn't terribly common, it's probably like 0.4% of all pregnancies, but if you ... And you wouldn't know, to be honest, if you're the psychotic person, you don't necessarily recognize that something is off. But this is where I think being the loved one of somebody who might be suffering from postpartum disorder is really important. So if you have a partner and they are not sleeping, they're really kind of making statements that don't seem to make sense. It's not usually overtly bizarre like, "Oh, the CIA is spying on me and my baby per se," but it might be things like preoccupation, some degree of hyper fixation and the intensity of which you hold to your beliefs is a little bit bizarre. That is an emergency and that requires seeing somebody who's a mental health provider right away.

And it may mean bringing your loved one to the emergency room that will feel scary, but it could very well save their life. So psychosis, big red flag, not sleeping for days, big red flag. Certainly if they are expressing any kind of suicidal ideation, that is a cry for help. So sometimes suicide ideation starts out very passive, this thought of, "I'm not a good mom, my child would be better off with a different mom." To have those thoughts, especially to have them several times is not normal. And I think if anyone ever expresses that degree of despair to you, I think despair is a really big red flag for psychiatric emergencies.

Dr. Erica Newlin:

Other than the red flags that you've mentioned, how can partners, family members or friends maybe recognize more of the subtle signs that a new parent is struggling?

Dr. Lulu Zhao:

I would look for withdrawal. So again, kind of not interacting with people the way that they normally would. Insomnia, if they are just sort of not taking care of themselves, if you have a partner and you say, "Hey, I've got the baby for a little bit. Why don't you go take a shower?" And they just don't, they're not feeding themselves well, that is a red flag. Just don't really seem like they're enjoying the relationship with the baby. So there's a lot of doubt and a lot of just worrying around the baby. So very common to have postpartum anxiety that manifests infant related worries, but if they're really not able to have happiness with that new parent experience, I think that is something that you should look out for as a partner. And you know your partner best. If they just don't seem like their normal selves, I would directly ask them about it.

Don't make an assumption that it's just because they're tired and they're a new mom. You should ask them, "Hey, how are you feeling? I noticed X, Y, Z, and is there anything I can do to support you? Can I do something concrete to help?" And I would try and say, don't ask struggling parents, what can I do to help? I would try and look around and say, "I can do the laundry. Why don't you go rest or let me make that bottle." Offer something concrete. And if you really don't see them perking up, even though you're providing them more resource-like support, I think that would be something I would encourage them to talk to with their Ob/Gyn or maybe even you can go with them to their postpartum visit and tell the doctors what you've observed.

Dr. Erica Newlin:

If someone is struggling or if they notice that their partner or family member is struggling and they make it to that doctor's appointment in their Ob/Gyn office or midwife or primary care, what can they expect from that visit and that initial discussion?

Dr. Lulu Zhao:

So ideally most Ob/Gyn offices should be doing some kind of screening for postpartum depression and anxiety that is a very strong recommendation from all of our professional organizations to screen for postpartum mood disorders. So that's one way that the doctor might already be looking to identify that there are some mental health struggles postpartum, but say the screening doesn't happen or maybe your partner actually doesn't screen positive, but you've noticed there are changes. I would directly tell the provider what you've observed. Again, you don't have to make a diagnosis, but you can just say, "This is what I've observed." And then the provider should be able to take a good history and give you some sense of what is normal versus what is not normal. And if it starts to seem like maybe what you're experiencing is a bigger struggle than the average parent, that provider should be prepared to offer you treatment right away.

So the American College of Obstetric and Gynecologists in their latest policy statement says that Ob/Gyn should be prepared to start treatment and then to refer to counseling and then if needed to refer to a higher level specialist. So for example, at the clinic, I commonly see people, and this is great, who have seen their provider postpartum, they have been identified as having a postpartum mood disorder, and that provider has already started medication for them, right? They've already started them on a first line medicine, like an SSRI like sertraline, but they need someone to follow that patient long term. So then they'll refer to women's behavioral health and we'll kind of take over from there and make sure that the medication is the right dose, that it's not causing side effects that are not tolerable, that the patient is in fact improving, and then to connect patients to therapy. So that would be how it should go.

Dr. Erica Newlin:

And you've already alluded to our next discussion of treatment. What treatment options are available for postpartum depression and anxiety?

Dr. Lulu Zhao:

There are a ton of treatment options available for postpartum depression and anxiety. There's always counseling. Counseling is basically helpful for everybody. I wish we all had access to our own personal counselor slash life coach all the time, but I think counseling is really important. And yes, it does take a bit of a time commitment, but it is so worth it to make that time commit for counseling. So that's number one. There's also just building up support, simple stuff, identifying what may be preventing you from nourishing yourself, getting sleep. Stressors like difficulty with breastfeeding can be helped or modified so that it's not putting you in a physical state where you're more prone to get depressed. And then there are of course prescription strength medications, right? So the most commonly used medication is something called an SSRI or a selective serotonin receptor inhibitor. And these are medications that have been around for decades now and well-studied in the perinatal period to treat both anxiety and depression.

And what they do is when you first take them, they increase the availability of a neurotransmitter called serotonin in your brain. And serotonin is our major emotion regulator in the brain. It has calming effects. It helps you with executive function to make decisions. It helps you with attention, helps you regulate your mood. And when you take an SSRI, the first immediate effect is that there is more serotonin in your brain, and that has kind of immediate level effects like perking your brain up. So if you're somebody who can't get out of bed because you're so depressed, all of a sudden maybe you can get out of bed. As you use it for longer, then you also start getting some calming properties, especially at higher doses. So for people with anxiety, as you get to higher doses of these SSRIs, you don't feel like the volume of your thoughts are so loud, you don't have all that rumination.

You're able to have that space to step away from the scary thought that you're having and say, "Okay, but how do I really react to this in the context of reality?" And then the other thing that's wonderful about SSRIs is that they provide with long-term use, what we call a positive cognitive bias for your brain. So your brain is neuroplastic. It's not stuck thinking in one way. It can change kind of its thought patterns. And when you take an SSRI for longer, it tends to push your thought patterns towards positive, helpful, productive thought patterns. And this is why even after you stop an SSRI, you don't just go back to being depressed. You actually can stay in remission for a long, long time and possibly never have another mood episode. So I commonly use SSRIs for my patients, and I do recommend that you use them for at least six months so that you have that time for your brain to form those new thought patterns so that you don't have that easy risk of relapse as soon as there's another stressor.

Some people have tried SSRIs before, or maybe SSRI is just not going to be the right fit for them because the side effects. There are other options too, right? So there's medications that work on your dopamine receptors. Some people will benefit from low doses of atypical antipsychotics, which work on your dopamine receptors as well, so that you don't have those kind of ruminative, almost paranoid thoughts when you're really anxious. Some people just need sleep medications, give them a few days of good sleep and they're kind of back to their normal functioning self. So there's a lot of different options. You're never stuck with just one option. And I encourage you to find a provider who can work with you to find options that will feel like a good fit for you.

Dr. Erica Newlin:

How can women prepare for emotional health during future pregnancies or postpartum periods?

Dr. Lulu Zhao:

I think recognizing what maybe made a postpartum period hard for you and preparing differently for the future is good. So I've had many women say, "Hey, the first time I had a baby I had no idea I was doing. I had no help. I didn't accept help from others. This time around, I'm going to let my mother-in-law come and do my dishes or I'm going to let my husband help out more at night." That is very helpful. I also think if you are a woman who maybe has had multiple episodes of depression or anxiety in your lifetime, yes, your risk for having a mood episode during a subsequent pregnancy is very high if you are untreated. And so women sometimes will take that knowledge and decide to be on treatment for the duration of the pregnancy. So they will stay on at SSRI. And honestly, those medicines have a very favorable safety profile in pregnancy and that can make a world of difference for someone who is prone to have mood changes during pregnancy.

Dr. Erica Newlin:

Well, this has been such a helpful discussion. Before we wrap up, let's leave our listeners with a final thought. For anyone experiencing emotional difficulties during pregnancy or postpartum, what's one key message you want them to remember?

Dr. Lulu Zhao:

I would like them to know that you deserve to have a good postpartum experience, and if you feel like you're struggling, there is help for you and you don't have to feel that way.

Dr. Erica Newlin:

What's one step that someone could take today to feel less alone and more supported?

Dr. Lulu Zhao:

So there is a great resource called Postpartum Support International. They have been around for a long time. And Postpartum International is unique in that it is managed and organized by people with a lived experience of postpartum mood disorders and they are free for anyone to use. They have an app that you can download and they offer really wonderful resources. They can connect you to mental health providers, therapists, medication prescribers, psychiatrists, et cetera, but they also have support groups and there are chapters in just about every state in the United States. So if you feel alone and you just want to explore what options are out there for you, I highly encourage you to check out Postpartum Support International.

Dr. Erica Newlin:

Great. Well, Dr. Zhao, thank you so much for joining me on the podcast today. For more information and helpful resources on postpartum depression, visit clevelandclinic.org/postpartum. That's clevelandclinic.org/postpartum. If you found this episode helpful, subscribe and share it with a friend. Remember, understanding your mental health is a powerful first step toward healing and feeling supported.

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.