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The tragedy that unfolded for a Duxbury family this month, where a mother has been accused of strangling her three young children before jumping out a window in a suspected suicide attempt, has sparked discussions around postpartum mental health.
Officials have not yet commented on a motive in the case, but in the week since the horrific situation unfolded, mental health experts have weighed in to try and explain how a mother could allegedly kill her own children. Mothers have also stepped forward on social media to share their own experiences with postpartum mood disorders and draw attention to the stigma surrounding mental health challenges.
Sara Cuthbertson, a member of the Lexington School Committee, is among those who have spoken out. She wrote on Twitter about the feelings of shame and isolation when she experienced postpartum depression, urging people to check in with their loved ones if it seems something “is off.”
Rosha Forman, a certified nurse midwife and director of midwifery services at Boston Medical Center, told Boston.com that seeing the broader attention and focus on peripartum and postpartum mood disorders, which are common for people who give birth, has been a “tiny” silver lining in the wake of the Duxbury tragedy.
“If you can see any silver lining in a case like this,” she said.
Below, what you should know about postpartum mood disorders, whether you are someone who is going to give birth or supporting a loved one through the experience.
Postpartum mood disorders should be thought of as a spectrum, Forman said.
At one end is an experience that is very common and a normal part of the postpartum transition that providers refer to as “the baby blues,” which generally occurs during the first two weeks after a person gives birth.
During that period, a person who has given birth may be feeling extra tearful, feeling the “highest highs and lowest lows.”
“That is not alarming,” Forman said. “That really is part of that huge hormonal and life transition into parenting [and] can happen to both men and women, honestly, in that big transition or any of the birthing people and the non-birthing parent. So that’s not something to be concerned about.”
In the middle of the spectrum is what’s considered postpartum depression or postpartum anxiety disorders, which is when after those first two weeks the mood swings don’t revolve and a person is still feeling down, depressed, or has a loss in interest in doing the things they normally would.
People can experience crying or a lot of anxiety focused on their baby and/or other children — or just anxiety over other parts of their life.
“We talk about, when partners or support people of that birthing person are watching, losing a sparkle,” Forman said. “If someone doesn’t have interest in caring for their baby or they’re feeling detached from their baby, I’d say that’s one of the warning signs that things are not going well and this might be something that we really do need to pay attention to.”
If you notice a real difference in the birthing person’s affect and how they’re acting, Forman advised talking to them about it and encouraging them to seek care.
But she also recommended the support person or non-birthing partner attend one of the postpartum or pediatric follow-up visits to ask the health care provider about postpartum mood disorders directly.
“I think sometimes these things can feel very complicated to disclose about yourself, but if your support person is asking about it, it can really help in diagnosing and therefore treating postpartum depression or anxiety disorders,” she said.
If a person is having any thoughts of harming themself or others, that is a warning sign that the person needs to seek immediate attention and should be brought to the hospital or medical care right away, Forman said.
“No one will ever get you in trouble for seeking care if you have thoughts of harming yourself or hurting someone else,” she said of the message she tells her own patients. “We know that this is a part of the disease process, and it is not someone’s fault. We want them to seek care, and they don’t have to be fearful of any reaction or forced separation from their children.”
Postpartum mood disorders along the “medium” range of the spectrum are common, she said, ranging from, in some studies, 6 percent to as high as 20 percent.
Forman said in her own personal practice, she sees closer to 20 percent of people suffering from some sort of mood disorder postpartum.
Postpartum psychosis, meanwhile, is “much, much more rare,” Forman said, estimating that she’s only seen it about two or three times in her career.
Rates are typically put at 1 in 500 to 1 in 1,000 people developing the serious condition at the far end of the spectrum, she said. It can emerge early in the postpartum period or later within the first year.
Symptoms of postpartum psychosis include visual or auditory hallucinations.
“If a support person to a birthing person notices that they’re saying things that don’t match with reality, I would say that should be a big trigger to seek care immediately,” Forman said.
Forman stressed that treatment should be a process of shared decision making between a patient, their support people, and their provider. But options for treating postpartum mood disorders range from making lifestyle changes to therapy to medication like antidepressants.
As you move along the spectrum from postpartum depression into postpartum psychosis stronger antipsychotic medications and antidepressants could be used.
Hospitalization is also almost always the first step in treating postpartum psychosis, to assess and stabilize the person and ensure they get a thorough psychiatric evaluation, she said.
The greatest risk factor for experiencing postpartum depression is having a history of depression or an anxiety disorder, either as an individual or in your family, Forman said.
She said that if you’ve experienced depression before, it’s important to disclose that during your pregnancy to your health care provider, who might then recommend or help ensure you have an established connection with a therapist since establishing a new relationship with a therapist when you’re in crisis can be hard.
Complex social factors can also come into play and elevate risk.
“If you’re experiencing a very stressful event in your life and it happens to coincide with the postpartum state, that will increase your risk of postpartum mood disorders,” Forman said. “Having a complex birth or having birth trauma increases people’s risk of postpartum depression. Having severe anemia or other medical complications can increase your risk. Having a baby in the NICU or a not well baby can increase your risk of postpartum depression.”
Black women are also at higher risk of experiencing postpartum depression, which Forman said is multifactorial.
“Racism and an experience of racism affects everything, so that certainly plays a piece to this,” she said.
Ultimately, no one is guaranteed to have a postpartum mood disorder and no one is exempt from developing one, she said.
“It’s one of those things that anybody deserves routine screening and a close relationship with a health care provider, with social support people and access to mental health services,” she said.
At Boston Medical Center and its associated health centers, Forman said screening for depression during pregnancy occurs three times — at the initial intake visit, once in the middle, and then once in the third trimester.
Forman said that there’s no end date for when a person might start experiencing depression or anxiety postpartum.
“The whole first year postpartum can be a large emotional transition, and I think peripartum and postpartum mood disorders absolutely can span that first year postpartum,” Forman said. “But generally you start to see signs within that two- to six-week period, generally … people are already feeling an increased level of anxiety or an increased level of depression at the six weeks. But mental health disorders are messy, and there’s no hard and fast line for when they begin or when they end, unfortunately.”
Usually, if by a person’s two-week postpartum checkup it seems they are still feeling very tearful or anxious, she said she’d probably want to see them again in a week or two to make sure it’s getting better and not worse.
Some pediatricians offices also incorporate postnatal depression screening tools into the pediatric visits that parents attend with their baby, Forman said.
It’s a location that Massachusetts legislators are pushing for having regular screenings.
“Screenings are critical,” State Rep. Joan Lovely, who represents the 2nd Essex District and is a co-chair of the Massachusetts Postpartum Depression Commission, told Boston.com.
Having more screenings at pediatric visits is one way the commission is working toward its goal of ensuring that perinatal and postnatal mental health care is accessible throughout the first year after anyone has given birth.
Often, Lovely pointed out, a mother who has just given birth may not see their obstetrician after the initial checkups and not everyone has access to a primary care physician.
The commission, which was established in 2010, has previously worked with the state’s Department of Public health to put into place reporting requirements for postpartum depression screenings and advocated for reimbursements for screenings in both pediatric and obstetric settings.
Forman said there remains a lot of stigma around postpartum mood disorders — and all mental health illnesses.
“There’s a sense in our culture often that birthing people should be able to do everything and make it look easy, and so when it’s hard, there can be shame associated with it not feeling easy,” she said. “And I would love to just be able to erase all that shame and stigma. Because it’s an absolutely challenging and impossible thing — to have a baby and have a physical, hormonal, lifestyle, mental health challenge all at the same time. It’s very difficult.”
With the nation’s health care services in crisis at a time when it is facing high demand, Forman said she’d like to see higher paying supported positions for access to mental health services and efforts made to ensure that insurance covers those services.
There is also a tremendous need for bilingual mental health providers, since the scarcity of such providers can be a real barrier to care, she said.
If you are experiencing postpartum depression or anxiety, Forman said you can call whatever phone number you used to seek care for concerns while you were pregnant — a midwifery or obstetrical care team will know how to help you. The labor and delivery department where you received care, an emergency room, or your pediatrician’s office are also all places where you can seek care in a safe way and where there will be services available.
“There are lots of support groups and online support groups that exist for people who have been diagnosed who are working through their treatment plan,” Forman said. “Breastfeeding support groups can often be a great place to find camaraderie and share stories and have support from other new parents. And if you were able to work with a doula in your pregnancy or in your postpartum, doulas can be very, very helpful in providing an extra support and extra resource if you’re suffering from perinatal mood disorders.”
The Massachusetts Child Psychiatry Access Program for Moms (MCPAP for Moms) has resources for pregnant and postpartum mothers, and there is a Postpartum Support International of Massachusetts Hotline — 866-472-1897 — and a state parental and caregiver stress line — that also offer support.
(You can view a full list of support services recommended by the state Department of Public Health here.)
What is paramount is that you share how you’re really doing and really feeling so that you can be connected with services that can help you feel better, Forman said.
“If you’re worried about anything at all, if you’re worried that you might have postpartum depression, the first thing to do would be to talk to that trusted care provider, that trusted health care provider,” she said. “There are so many things we can do to help you feel better, and we always always want you to share how you’re doing so we can help you get back on the road to wellness.”
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