Provider Newsletter | Feburary 2019
Planning for Another Baby After a PMAD
Thinking Ahead
Having another child after experiencing depression, anxiety, or trauma can be complex. In addition to the overwhelming addition of another child, parents who have experienced a previous perinatal mood or anxiety disorder have another set of considerations- am I ready and able to do it again? What if I experience depression again? What will it do to my relationship? Additionally, it is not uncommon for parents to have not processed their first experience with a trained therapist and to have "muddled through" the first time. As they are contemplating another child there is often strong feelings that they can't go through it again, at least not in the same way. All of these are very common feelings and it can help to have more information and also to make a plan. This newsletter will give providers the information and tools to support families in planning for a smoother transition as they bring another child into their family.



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In This Issue
Recurance Rates and Risk Factors
First Person Story
Preparing for Another Baby
Planning Worksheet
Recurrence Rates and Risk Factors in Perinatal Mood Disorders
Anyone who works regularly with perinatal women will eventually find themselves face to face with a worried mother in their office thinking about becoming pregnant or already pregnant with her second (or third) child. The most likely question that this woman will ask is “What are my chances of getting postpartum depression (anxiety, psychosis) again?” Sheila Marcus, MD, psychiatrist and clinical professor of psychiatry at the University of Michigan, cites the risks as follows: 30% for unipolar depression, 50% for bipolar depression and 70% for postpartum psychosis. Some women have such horrendous mood or psychotic complications that they decide against having another child because for them, it just isn’t worth the risk. While the DSM5 does have a depression modifier for postpartum onset, it restricts onset of depression to one month postpartum. In reality, postpartum mood disorders usually happen between one and six months, with three to four months being the most common time of onset.

While many perinatal professionals counsel their patients/clients regularly about the likelihood for recurrence of perinatal mood disorders, a quick review of the literature reveals little, and conflicting, research on this topic. One double-blind study compared a group of women who had suffered postpartum major depression. The women were randomly assigned to either a placebo or Nortriptyline group. No significant results were found with the Nortriptyline group providing no benefits beyond that provided for by the placebo group. A cohort study using Danish medical records comparing recurrence rates of women with perinatal mood and anxiety disorders hospitalized for their first birth found the recurrence rate to be 55.4 per 100 persons for the second birth. For women in this cohort taking postpartum antidepressant medication, the rate was reduced to 35.0 per 100 persons. For non-hospitalized women, the estimated recurrence risk of postpartum affective disorders was 15% for women taking postpartum antidepressant medication subsequent to the first birth and 21% for women not taking psychotropic medication, with the observed risk for depression remaining elevated for several years. Postpartum affective disorders including postpartum depression affect more than one in 200 women with no prior history of mood and anxiety disorders. This raises the risk for subsequent affective disorders.

Literature on the role of bi-polar disorder in perinatal mood disorders is even more sparse. One study sought to determine the recurrence rate of perinatal women with bi-polar disorder who discontinued their medication. For the first 40 weeks after lithium discontinuation, the recurrence rates were nearly identical between pregnant and nonpregnant women but then rose sharply during the postpartum period. The risk of bi-polar symptoms returning lowered significantly when medication was reduced gradually.

Knowledge of known risk factors for perinatal mood and anxiety disorders is also helpful in determining the likelihood of a recurrence in a subsequent pregnancy. A meta-analysis of 84 studies from the 1990’s was completed to determine the main risk factors for postpartum depression. In order of size effect (from greatest to least), these were the risk factors which were found: prenatal depression, self esteem, childcare stress, prenatal anxiety, life stress, marital relationship, history of previous depression, infant temperament, maternity blues, marital status, socioeconomic status and unplanned/unwanted pregnancy. In another comprehensive, more recent study led by Cheryl Beck, depression or anxiety during pregnancy, past history of psychiatric illness, life events, social support, neuroticism, marital relationship, and socioeconomic status were all found to be correlated with recurrence of mood and anxiety disorders during the postpartum period. A large prospective study occurring just last year found similar results but also found that antenatal depressive symptoms were as common as postpartum depressive symptoms in perinatal women with mood disorders.

Much more research is needed to more accurately determine how women will fare with subsequent pregnancies after experiencing anxiety, depression and psychosis during the perinatal period of earlier births. It is helpful to keep in mind that perinatal mood disorders often go unreported. Women of color have higher rates of perinatal depression and anxiety but their needs frequently go unaddressed. While research knowledge slowly grows, the studies do seem to agree that a history of depression and/or anxiety either in one’s history or during pregnancy is a robust predictor for postpartum depression and anxiety. The studies also largely support the use of psychotropic medication as a powerful tool in reducing the recurrence rates of perinatal mood disorders. Finally, studies on perinatal risk factors consistently find that psycho-social factors play an important role in whether or not women develop prenatal and postpartum anxiety and mood disorders. This finding strongly suggests that psychotherapy, support groups and other forms of support (i.e. lactation consultant, doula and family support etc.) may play an important role in helping women recover from the most common side effect of pregnancy, birth and the postpartum period whether the mother is having her first or fourth child. 

  1. Vann, M., Will Postpartum Depression Return the Second Time Around? Everyday Health.
  2. Postpartum Depression Timeline. Retrieved from https://www.postpartumdepression.org/postpartum-depression/timeline/.
  3. Rasmusen, M-L.Hl, Strom, M. Risk, Treatment Duration and Recurrence Risk of Postpartum Affect Disorder in Women with no Prior Psychiatric History: A Population-Based Cohort Study. https://doi.org/10.1371/journal.pmed.1002392 PLOS-Medicine, Sept. 26, 2017
  4. Viguera, A.C.and Nonacs, R. et al. Risk of recurrence of bipolar disorder in pregnant and nonpregnant women after discontinuing lithium maintenance. American Journal of Psychiatry.2000;157(2):179-84.
  5. Beck, C.T. Predictors of Postpartum Depression: An Update. Nurs Res. 2001; 5(5):275-85.
  6. Robertson, E., Grace, S. et al, Antenatal Risk Factor for Postpartum Depression: A Synthesis of Recent Literature. General Hospital Psychiatry. 2004;26(4):289-295.
  7. Milgrom, J. and Gemmill, A.W. et al., Antenatal Risk Factor for Postnatal Depression: A Large Prospective Study,Journal of Affective Disorders. Journal of Affective Disorders. 2008;108 147-157.
  8. Ford, S. (Ed.) (2011, October 26) Postpartum Depression”Often Unreported”. Retrieved from https://www.nursingtimes.net/clinical-archive/postnatal-depression-often-unreported/5036928.article
  9. Karras, T. PMADs – Such as PPD and Anxiety – in African American Moms: Why Black Women Face a Higher Risk but Receive Less Treatment. Retrieved from https://www.seleRni.org/advice-support/2018/3/16/pmads-such-as-ppd-and-anxiety-in-african-american-moms.
  10. Robertson, E., Grace, S. et al, Antenatal Risk Factor for Postpartum Depression: A Synthesis of Recent Literature. General Hospital Psychiatry. 2004;26(4):289-295.
  11. Field, T. and Diego, M. et al. Yoga and Massage Therapy Reduce Prenatal Depression and Prematurity. Journal of Bodywork and Movement Therapy. 2012;16(2):204-9.

Terri Buysse is a clinical psychologist with a private psychotherapy practice in Edmonds and Everett, Washington. She specializes in perinatal, parenting, and trauma work. She is one of the facilitators for Little Sprouts, a new mothers' support group in Mountlake Terrace, and is a member of Perinatal Support Washington.
PPMDs, My Second Baby and Me
Hi, my name is Sabine and I suffered from Postpartum Anxiety, Depression and OCD. This is my story on deciding to have another child. If you are thinking about having another child after experiencing a postpartum mood disorder, I want you to know that you will make the right choice, you are strong and you are not alone.
I finally sought out help 18 months postpartum. It took 6 months after my first baby decided to self-wean. 12 months was my personal expectation for breastfeeding. I wasn’t prepared for the sudden hormonal shift that resulted in the worst thing that has ever happened to me, Postpartum Mood Disorders (PPMD). Suddenly I was experiencing my undiagnosed symptoms: hyper analytical and anxiety riddled thinking patterns, horrific intrusive thoughts, and suicidal ideations. Suddenly I went from a happy-go-lucky and ambitious person to a mess of an individual with extreme shame, confusion and rage. I lived like this for so long because I didn’t know who to tell and several people told me “Oh hun, it will be better.” “Enjoy every precious moment with your baby, you’ll never have them back.” No one heard me. No one saw that I was suffering tremendously. No one could see the intrusive thoughts – ugh, who would want to see those!

I am forever grateful for stumbling into the South Sound Partum Support Group for mothers. The facilitator literally saved my life. That first day I was the only one to show up and spent almost 2 hours crying in her arms. What a huge relief, I was not alone in what I was experiencing; I wasn’t a horrible person with a black soul.

She very quickly realized that I was probably experiencing one or more PPMDs. After holding space for me, she determined that sleep deprivation and my past and current life experiences had made me a prime candidate for what I like to call, the “Mother Mental Meltdown”. My risk factors were:
being fairly new to the community because of chosen geographic therapy,
epigenetic trauma,
from an immigrant family,
member of the LGBTQ community,
reluctant Type A personality
past emotional and physical abuse and assault,
history of personal depression,
history of familial depression, anxiety, OCD, and
financial and career victim of the 2008 Great Recession.

I think that’s all, its been 8 years and thankfully some of the details have become hazy.

I was familiar with therapy and once I knew what was going on, I jumped feet first into research, understanding and finally healing mode. I regularly attended the support group whether I was symptomatic or not, went to therapy, decided on trying pharmaceuticals to jump start my biochemistry back into alignment, and became an activist. I should add that I have a master’s degree in Public Health with an emphasis on Health Behaviors. I had no time to lose and was/am grateful that I had the privileges that allowed me to learn as quickly as possible about PPMDs and start implementing ways of getting help to families as quickly as possible.

But my other motivator was my family. My husband and I had always believed that a 2-child family structure as ideal. But I was terrified by the idea of experiencing the trauma of PPMDs again. I knew the chances of them re-occurring were extremely high and so my therapist and I came up with a plan. I, finally, fully opened up to my husband. After grasping the intensity of PPMDs, he committed to be an active part of the plan.

It was a multi-pronged approach and I hope that I can describe it as accurately for you as possible.
We attended couples counseling to understand what was currently happening, what to expect if symptoms re-occur and developing skills to cope, heal and hold the ramifications of those symptoms.
We developed and implemented a weening schedule of the sertraline I was taking. It also included a plan for if I needed to medicate again. Which I ended up doing at a very low dose, the last third of the pregnancy.

We learned how to ask for help in the new community that I found myself in and then, actually asking for help. This help included food trains, assistance with household chores, child care and social visits. Asking for help was so incredibly hard for me; German stoicism and ego were a huge hindrance for me.
We recommitted to a healthy lifestyle. We already were a health-conscious family, but the recommitment underlined the key pieces of nutrition, activity and emotional wellbeing.

I turned into an activist and committed to doing what I could to help pave the path for other mothers and families to avoid PPMDs. It was vital for me to continue attending support group while pregnant, so others could see that there is hope and healing can happen.

The plan worked for us. It really did. Yes, the symptoms returned but I knew what was happening and could immediately attend to them. The first symptom was anxiety while pregnant, which made me realize that I had all the symptoms while pregnant the first time around. My therapist helped us through the peri and postnatal periods. After the birth I continued the low dose sertraline to control my over active brain and I’m happy to report I only had a hand full of intrusive thoughts. What a huge relief!

So what has happened since then and now? I get out of bed and am ready for the day! Our family is happy and well adjusted, and we have many camping adventures. I continue to work to dismantle the stigma of mental illness and support families with young children. I’ve been known to distract a toddler or two in grocery store, so the parent can finish shopping. Life is good. It’s different, but it’s good.

Sabine lives in the Pacific Northwest with her loving husband, fantastic kids, a wiggly dog and cuddly kitty. When she isn't speaking up about public health issues, she likes to go camping, do yoga, nap and laugh at silly puns. She is a survivor and thrivor in this wonderful, mixed up world. Life is hard but that's what makes it interesting!
Preparing for PMADs in Subsequent Pregnancies
As providers specializing in postpartum support, we all will encounter clients who are looking for support for an upcoming delivery after experiencing symptoms of PMAD. As providers it is our role to support our clients in planning and preparing for the possibility of a second experience with a PMAD. Our role is a unique one. We become an advocate, a detective and a soft place to land for many of our clients who become pregnant after a previously difficult postpartum experience.

Preparing for PMAD means exploring the client’s previous history. If this is a new client coming to therapy because she is pregnant and looking for help so she doesn’t struggle like she did ‘before’ then you know that you need to explore her history to develop a comprehensive support and resource system. If she is a client who you have had before you may be able to draw upon your previous experience with the client to offer support.

With a new client, gathering history may be lengthy, but can also be an opportunity to align and develop a therapeutic relationship. If you are informed that your client had a previous PMAD, starting with how she was diagnosed is a good place to begin. Who diagnosed her? Why did they diagnose her? And what treatment, if any, was provided? If a provider or therapist was seeing her, why is she not seeking support from that provider again? It will be important to understand how she felt supported or not supported if this is the case. This will be a benefit for ongoing treatment as it will be helpful to have a sneak peek into what intervention style may benefit or be a roadblock for you as a team.

If a client self diagnosed, but never had therapy or support, find out how she diagnosed herself. A self-diagnosed client may have benefited from services, but did not have the resources to obtain them. She also may have had symptoms but did not recognize them as significantly impairing, or the opposite- they were significantly impairing but she felt uncomfortable accessing or asking for help. This is a good place to ask about symptoms. “How did you know something wasn’t right?” Often this will lead you to the second step in finding out what acuity of symptoms were. If we know what symptoms previously were experienced, it gives providers a good idea to prepare at that level and above. It is important for providers to support their clients in understanding the possibility for PMADS to reoccur, and to educate clients about what to look for and how to draw on resources and support recovery.

If your client has previously been diagnosed and saw a provider previously, clarify the symptoms and how they were addressed. What treatments were provided? Did the client find the treatments successful? This will take you in one of two directions. If the client found some treatments successful, draw upon those. Empower her to begin to practice these skills if possible. Encouraging her to draw strength in her ability can offer reassurance and confidence in herself as well as in the process of self-care. One example of this may be a client that mentions that breathing deeply helped her to be mindful and relax in moments of stress or anxiety. Encouraging her to practice this skill with you in session as well as at home, gives a tool that was previously useful and easily incorporated into daily life before baby comes and during the postpartum period as well.

If she states that nothing worked, this is where detective work comes in handy. Joining with her by asking what was tried, and if there were any things that helped her symptoms decrease- treatment or otherwise? In both cases, finding out how long it took for symptoms to subside or reduce will be something to take note of. Taking a baseline as well as where she feels she is today. Just because her ‘baby’ is 2 don’t assume that her symptoms have disappeared. I have had clients who state that they have felt better since their baby got older, but that they still don’t feel 100% and now being pregnant is making them scared that they wont ever feel better again. In fact, you may experience clients coming to counseling for PMADs for the first time because of just that. They are fearful that this time will be worse and they will never feel ‘the same again’.

Once you have gathered your initial history of symptoms and treatments, it is time to gather an understanding of supports and risk factors. Every client comes to therapy with a different history, experience and story. It is important with PMADs that you don’t make any assumptions. A client that presents well may have limited supports and a minimal network of friends or family. Just as likely, a client who is presenting severe symptoms with hopelessness and feelings of isolation may have an extensive support network that is unaware of how to help.

To gather resources and supports identify:

  • Family members. Immediate and extended. I say this because family members may not be easily accessible, however may be willing to at the drop of a hat fly, drive or visit as needed to support the client in need. Just as important is asking about how supportive the spouse or partner was in the previous experience.
  • Friends. What is her social network. Circle of friends, groups engaged in, etc.
  • Providers in her corner. Exploring what her experience with her OB/Midwife/MD in her previous experience and currently will be important in developing a healthy supportive team for your client to draw upon when she needs it. If she had medication management previously, it will be important for you to connect or support her in reaching out to ask if she will be able to utilize that provider in the future if she needs, etc.
  • Skills. What skills does your client already have in her ‘toolbox’ and what can you support her in developing proactively- mindfulness, self care, grounding, breathing skills, etc.

Once you have gathered resources, you can begin to explore risk factors, if you haven’t already taken note of some. Risk factors include any obstruction to health, treatment access, etc. that can play a factor in recovery or magnification of symptoms. Identifying resources that they have and then building on them as you simultaneously identify risk factors and develop a plan to plug them into resources as appropriate or plan to minimize the impact. Common risk factors to consider:

  • Socially: What is your client already plugged into? What could she be connected with? Friends, YMCA, Activities/Mom support groups/etc.
  • Previous Diagnosis of PMAD as well as Mental Health Diagnosis: Encourage ongoing engagement with medical providers, voicing concerns with medications, etc. Identifying previous symptoms and Diagnosis. A diagnosis of Postpartum Psychosis previously or a diagnosis of Bipolar may mean that you have a more comprehensive plan and preplanning may have more contact with providers before delivery.
  • Previous traumatic birth experience: Clients who have had a previous traumatic birth experience may feel a variety of emotions related to being pregnant and the upcoming delivery. Anxiety, worry, PTS symptoms all may be playing a role in the anticipation of delivery.
  • Hormone Sensitivity: Understanding a clients sensitivity related to hormones- PMS, PMDD, etc. and symptoms that are experienced during these times can be an important part of education for clients and may play a role in the perinatal time.
  • Support of Family:How involved was partner/spouse, what family support was offered to a single parent household
  • Age(s) of other child(ren). Caring for one child vs. more + an infant can play a role in stress, sleep, and finances.
  • Financial: Finances impact a significant part of our lives and the lives of our clients. Clients struggling financially may struggle to attend sessions, pay for daily expenses, housing, insurance, and access to childcare, etc.

As a therapist in the area of PMADs its important to have a wide plethora of resources to pass on to your clients. Having contact points for community resources will be beneficial in your treatment planning for clients coming to therapy for subsequent deliveries after PMADs. It is important that clients find their therapist as a resource to feel better but also as a ‘director’ to connect them to resources and contact points. These resources you should be familiar in your community with would be in each of the areas above in Risk Factors .

Resources to be familiar with:
  • Financial. Know what resources would benefit clients. Low-income assistance programs, local rec centers, even a contact at the state level for clients needing to navigate the WIC system.
  • Transportation. Is your client elgible for Meidcaid transportation services? Remebering to refer to places that are easy to access and dont require a car.
  • Social. Be sure to have community resources that are free are low cost- play groups, free days at museums,mother groups, library story times, free membership fee days at the YMCA, etc. Having resources for moms who are in the later stages of recovery can support in feeling ‘plugged in’ and can support social connections with other parents.
  • Prescriber/Mental Health Providers/OB/Midwifes. Have a list of contacts to connect/consult or refer is a powerful resource for providers. Often times having a contact for medication provider can make it less confusing for clients to have a direct contact with and can be beneficial for providers when we have questions or need support with a possible referral. Just as important is finding and having resources for intensive outpatient services in your area and contacts at the hospital if you have a referral for inpatient services.

Working with an expecting mama who is concerned about a ‘repeat’ of her previous PMAD experience can be rewarding for both you and your client. Recognizing and appreciating her commitment to ‘feeling better’ and taking care of herself is the first step to pre-planning for her next experience. Taking into account the information she shares and creating a safe nurturing environment is the key to pre-planning for a PMAD. If a client doesn’t feel safe or heard, we wont be able to do our work.

We, as providers know that every pregnancy is different and so is every delivery and parenting experience! Clients may be coming to us feeling scared and concerned that it will be a repeat of their last experience. Supporting your client in planning for what they can plan for, educating them and offering them power in their choices and knowing that you will be available to support them if things they didn’t plan for do happen.

Teresa M. Eltrich-Auvil MS, NCC, LMHC is a provider specializing in PMAD as well as other women’s issues, including miscarriage and infertility. Teresa has been committed to advocacy and promoting awareness and education surrounding the perinatal period since 2006. Her practice Picket Fence Therapy & Consulting is out of Puyallup, Wa in the South Puget Sound. www.picketfencetherapy.com

A New Tool: The Preplanning Worksheet
Perinatal Support Washington has created a worksheet to help providers and parents think through previous experiences and create strategies and plans to prevent or reduce a subsequent mood or anxiety disorder. You can view this tool and all our tools at our website.
Upcoming Events
Small Group Clinical Consultation and Training
Perinatal Support Washington is pleased to be partnering with local area perinatal specialists to provide Clinical Consult Groups on perinatal mood and anxiety disorders. Consult groups meet monthly for 10 months and will cover in-depth treatment issues for the spectrum of perinatal mental health. Additionally they offer a community and forum to meet with peers and colleagues to confidentially discuss clinical issues. They are suitable for all mental health practitioners. We have 3 consultation groups starting this spring. This training meets the requirement for the Postpartum Support International Advanced Training for Perinatal Mental Health Certificate. 

Redmond, WA led by Heidi Koss, LMHC
Meets for 10 months on the 2nd Friday of the month from 10am-12pm
Begins Friday, March 8th

Bellingham, WA led by local Bellingham therapist Michelle Anderson, LMHC
Meets for 10 months on the 2nd Wednesday of each month, 8:30-10:30 am
Begins Wednesday March 13th

Online via video-conference, led by Heidi Koss, LMHC
Meets for 10 month on the 2nd Friday of each month, 1:00pm-3:00pm, 
Begins Friday, April 12th

MORE INFO AND REGISTRATION CAN BE FOUND ON OUR CONTINUING EDUCATION PAGE


Trauma and Birth:
Multidisciplinary Approaches to Prevention and Healing
Mar 28th- March 30th
Seattle, WA
This 3 day conference will bring together over 200 providers from diverse disciplines in the field of perinatal health. The focus of this event is to examine the implications of trauma prior to childbirth, during childbirth, and the subsequent postpartum mental health of new parents including postpartum depression, anxiety, and PTSD. We will focus on systems of care and personal risk factors that increase traumatic birth outcomes, as well as on prevention and treatment approaches to mitigate the impact of trauma for parents and prevent transmission of trauma to infants and young children.

Would your client benefit from talking to another parent "whose been there"?
Our Warm Line offer peer support for new parents. 1-888-404-7763
Perinatal Support Washington has a toll[-free support line for new parents. Leave a message, and a trained volunteer will return your call within 24 hours. The line is staffed by a parent who has experienced a perinatal mood and/or anxiety disorder and has recovered fully, or a licensed therapist with specialized training in perinatal mental health.

We provide warm, understanding, effective, and private support, as well as professional referrals to providers who can help. We also provide details about community support groups and resources and information in the community and online.

FOR DADS- Would it feel more comfortable to talk with a dad who has been through his own perinatal mood or anxiety disorder, or has supported a partner who has? Call our warm line and ask to talk with a dad.
Giving To Perinatal Support Washington
EMPLOYEE GIVING
Are you a Microsoft or King County employee or spouse of one? Please consider supporting us through your respective workplace giving programs. For King County employees, our code is 9187. Our tax ID is 91-1448669. If you are looking for us, be sure to check our old and new name (old name: Perinatal Support International of Washington).
WARMLINE: 1-888-404-7763 (PPMD)

Support, Education, Referral
Perinatal Support Washington | perinatalsupport.org
a state chapter of Postpartum Support International