Perinatal Mood and Anxiety Disorders (PMADS): The Hidden Motherhood Struggle

In 2000, my book Natural Health After Birth was still an early voice in the wilderness on the  conversation on postpartum depression – a topic which was then still only whispered about, and was largely taboo – because what new mom isn’t happy? 

In reality, many. Motherhood, even on the best of days, is an enormous job and requires incredible inner landscape and life shifts. 

For many new mothers there are deep valleys and mountains to climb. 

• 1 in 5 pregnant and new mothers experiences a PMAD- Perinatal Mood and Anxiety Disorders (PMADS)
• 1 in every 10 women/birthing people endures postpartum anxiety after GIVING birth and 6% of women/birthing people experience it while still pregnant.
• More than 15% of women/birthing people experience postpartum depression, perhaps even more given that the diagnosis goes highly unreported.
• 3-5% of mothers/birthing people report feeling as though they cannot escape  intrusive, irrational and upsetting thoughts about something happening to the baby unless they engage in a repetitive act.
• While rare, postpartum psychosis is a dangerous and devastating condition that requires prompt medical care. 
• PMADS are the #1 complication associated with birth
• PMADS are the #2 cause of maternal mortality

It’s not just you. You're not crazy. You're not a bad mom. You're not alone.

These are words – and deep beliefs – that resonate through and form the backbone of the work of today’s guests, Catherine Birndorf, MD, and Paige Bellenbaum, LMSW. Catherine and Paige are dedicated to changing the perinatal mental health terrain, and they do it through The Motherhood Center, a place of radical acceptance, nurturance, and individual and group support.

On today’s episode, we pull back the curtain on motherhood and redefine what is considered “normal” and “typical”. With Perinatal Mood and Anxiety Disorders (PMADS) being the #1 complication associated with birth and the #2 cause of maternal mortality, this is a critical conversation. We unpack why it’s so important that we talk more about these conditions, how to do your best to prevent PMADs, and what to do if you or someone you love has symptoms. 

Aviva, Paige, and Catherine discuss: 

• The definition of Perinatal Mood and Anxiety Disorders (PMADS) and the different diagnoses that fall under the PMADS umbrella 
• What PMADS taboos still exist today, why this needs to change, and how Roe v. Wade affects these taboos 
• Paige and Catherine’s personal stories with perinatal mood disorders and what brought them to the point of specializing in PMADS and opening the motherhood center 
• The kinds of physical and psychological feelings and symptoms associated with PMADs and signs birthing people and their providers should watch out for 
• Why we need to move in the direction of making it mandatory for OB-GYNs, midwives, pediatricians, and any providers who come in contact with newer expecting mothers to begin educating their patients about PMADS and screening for symptoms  
• The effects of the pandemic, social isolation, and potential cultural contributors on PMADS  
• The role of medication and psychotherapy in treating conditions 

Catherine Birndorf is a reproductive psychiatrist and the co-founder, CEO, and medical director of The Motherhood Center of New York. Dr. Birndorf is the founding director of the Payne Whitney Women’s Program at Weill Cornell Medicine and a clinical associate professor of psychiatry and obstetrics & gynecology. Dr. Birndorf was a regular mental health columnist for Self Magazine and has appeared on numerous television programs, including The Today Show, Good Morning America, MSNBC, and CNN. She is the author of The Nine Rooms of Happiness and What No One Tells You: A Guide to Your Emotions from Pregnancy to Motherhood.  

Paige Bellenbaum is the founding director and chief external relations officer at The Motherhood Center of New York. For the past 20 years, she has worked in public policy, advocacy, and clinical care with various populations, including homeless families and incarcerated young adults. She drafted legislation in New York State championed by Senator Liz Krueger, mandating hospitals to provide education on PMADS and strongly encouraging screening of all new and expecting mothers, signed into law in 2014. She has appeared on the Today Show, Good Morning America, NPR, PBS Newshour, Fortune, The New York Times, and The Wall Street Journal. 

To contact The Motherhood Center:

Website: themotherhoodcenter.com

Phone: 212-335-0034

For more on prenatal and postpartum depression, check out this article – Natural Approaches to Depression in Pregnancy – and this podcast – Facing and Healing Postpartum Anxiety with Gabby Bernstein – on my website.

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This conversation has been edited for length and clarity.

Aviva: These are the voices of mothers who have come through the Motherhood Center of New York. In 2000, my book “Natural Health After Birth” was still an early voice in the wilderness in the conversation of postpartum depression, a topic which was then still largely taboo. Why? The assumption is that every new mom should be happy. In reality, motherhood is an enormous job even on the best days, and requires an incredible landscape shift for many new moms – both inwardly and outwardly. 

There are deep valleys and mountains to climb for new moms. One in five pregnant and new mothers experiences a PMAD – a Perinatal Mood and Anxiety Disorder. One in every 10 women and birthing people endures postpartum anxiety after giving birth, and 6% of women and birthing people experience it while still pregnant. More than 15% of women and birthing people experience postpartum depression – perhaps even more, given that the diagnosis goes highly unreported. 3% to 5% of mothers and birthing people report feeling as though they cannot escape intrusive, irrational, and upsetting thoughts about something happening to the baby unless they engage in repetitive acts – OCD behaviors. While rare, postpartum psychosis is a dangerous and devastating condition that requires prompt medical care.

PMADs are the number one complication associated with birth, and the number two cause of maternal mortality. My guests today, Catherine Birndorf, MD and Paige Bellenbaum, LMSW, are dedicated to changing the perinatal mental health terrain through The Motherhood Center of New York, a place of radical acceptance and nurturance. The center is a place that offers individual and group support for pregnant people and new mothers. It’s a place that understands their diverse needs and helps them learn the transitional skills necessary in order to survive and thrive as mothers. It teaches them how to ease the transition into motherhood and heal from devastating conditions like pre and postpartum anxiety, depression, and OCD. I know that some of this stuff is scary to hear about, especially if you're pregnant now or plan to be down the road. My guest and I have a message for you.

Every disorder we are going to talk about is both temporary and treatable. We're going to unpack why it's so important to talk about these conditions, how to do your best to prevent PMs when possible, and what to do if you or someone you love has symptoms.

Catherine: Thank you for having us.

Aviva: I love being with you. I'm so inspired and moved by everything you do. Let's start by defining PMADs, so that everyone knows what we're talking about. I trust that you do this all the time, so tag team however you want to.

Catherine: Thank you again, Aviva, for having us. We are so privileged to be here and to be able to get this much time to talk about our favorite subject, PMADS – Perinatal Mood and Anxiety Disorders. I say it slowly and deliberately, because that is the acronym for a whole host of conditions and illnesses that we are trying to lump together. We lump them together so that if anybody feels anything that is related to becoming a new mother, they will be able to find themselves there. The reason I say it that way is because we used to just say postpartum depression. Before that, we didn't say anything – we weren't talking about it. Once we started talking about it, we would use the terms “postpartum” or “postpartum depression”, but people would say things like “Well, I'm pregnant and I'm anxious – am I included in there?” It became this big term that Paige and I don't totally love because it has the word mad in it. However, it's the best term we can find at the moment that holds everyone within it and allows them to  find themselves there if they should be struggling with any kind of mental health issue related to the perinatal period – before, during and after pregnancy. I hope that explains it.

Paige: There's a number of different diagnoses that fall under the PMAD umbrella – some that your listeners might be familiar with, and some they might not. To Dr. Burner's point, it includes not only depression, but anxiety, obsessive compulsive disorder, bipolar disorder, post traumatic stress disorder, and in rare but very serious instances, postpartum psychosis.

Aviva: Thank you – it does help to have that clarified, because I think that many people believe something along the lines of “Oh, well this isn’t postpartum depression, so it must just be something normal”, and this leads them to ignore it.

With this podcast, I am committed to breaking down taboos and shining a light on what's hidden. You all know that I've been in maternal health for a really long time now. I started my midwifery journey in 1981, and it wasn't until the late nineties or 2000 that Marie Osmond came forward about her PPD. It was almost like tabloid fodder at the time; I think that she was initially treated as a joke in some ways. However, for so many women it was like the revelation of a dirty little secret that opened the lid on a hermetically sealed jar of postpartum realities. Why was PPD originally postpartum depression? What taboos persist now, and why? Why does this need to change?

Paige: I think that it remains taboo today for the same reasons that it was taboo 20 years ago; 50 years ago; even 150 years ago. There is a very specific interpretation of what it means to be a mother. Motherhood is very romanticized and glamorized, to an extent. When we hear the word motherhood, many of us automatically go to that place of “blissful, amazing, best thing that’s ever happened to me”; unconditional love and bond with my baby; glowing; happy – all of these things that we associate with the perinatal period. What ends up happening in that kind of romanticized version of motherhood is that all the other parts get left out. When we have this very specific definition of what it is to be a mother and what it is to feel like a mother, we don't make any room for all of the other complicated, normal, and very real aspects of the transition to motherhood.

What we are left with is “If I don't feel that way, then there's something wrong with me”. “I'm failing at this. I'm doing it wrong.” “Everybody else has this figured out. I'm the only one who feels like I made a mistake – who wishes I never had this baby. The only one who is so anxious that I can't even be in the same room with the baby.” The list of symptoms goes on and on; it is a deep, dark secret. It always was. To your point, there are more and more people who are coming forward to share their stories, which helps to destigmatize. Unfortunately, the stigmas still very much exist. I think the fans are flamed in this new Instagram, social media world we live in, because that's all we see –  the blissful part.

Aviva: It's so curated – so dangerous and misleading. It isn’t that motherhood can't be all those things; I didn’t experience postpartum depression anxiety, diagnostically. I had a relatively easy transition compared to what a lot of women go through. But even within that sort of “normal” range of the experience, it was often really hard. It was helpful for me to already be studying midwifery and around other mothers with whom I could be honest about my experience.  I think that sometimes just vocalizing it, even when it's the “normal” stuff, is helpful. We have to be able to tell the truth, because it's so overwhelming. 

Catherine: Very true. I hate to bring this up so early on, but I think that in the post Roe era the idea that motherhood is something that everybody wants and should have only moves us back in terms of taboo. It’s going to keep it entrenched; it’s going to make it worse. We have a bigger problem ahead of us – not just in terms of reproductive rights and women's healthcare at large, but in terms of what motherhood is, because now we're being told what it is by the legal system. We are being pigeonholed more than ever. To your point, Aviva – you don't have to have a diagnosis to struggle or feel ambivalent about the challenges of becoming a new mother. That is the norm. 

Aviva: I'm going to call it “compulsory motherhood”. We do know from pretty well conducted studies that the inability to have an abortion, if that is what you need or want to do, statistically increases the rates of perinatal anxiety, depression, and other poor outcomes for mothers across the board. Yeah. I feel that our collective and individual work as human beings is so often a reflection of our own journey – things that shape us along our educational path, or that happen to enter our lives and put us on a path.  I would love to hear each of your stories about what brought you to the point of specializing in PMADs, and to opening The Motherhood Center. I know that you're both deeply invested in this work. Paige, you specifically had a very trying experience with perinatal mood disorder.

Paige: I did. Despite the fact that it was 16 years ago, I can still touch it and feel it like it was yesterday. I trained as a clinical social worker during the pregnancy of my first child, and I highlight this because even as a clinician, when I started to experience symptoms of anxiety and depression, I didn't know what they were. I didn't know if it was or wasn’t normal, and I didn't really talk to anyone about it. When my son was born, I rather quickly started to experience very acute symptoms, primarily of depression and anxiety. I didn't tell anyone; I kept it a secret for about 6 months. It  was very difficult for me to get out of the house, to care for myself and for the baby. I felt like I'd made the biggest mistake of my life.

I wished I'd never had my son. I wanted to buy a one way ticket to another country and never come back. I didn't want to be alive, and I felt like the biggest failure as a mother – the biggest failure of anyone on the entire planet. I was petrified to tell anybody that I was feeling that way, because what kind of a mother would feel that way about her own child? 

One day when I was taking my son for a walk on the sidewalk and everything felt gray and dark. It was the first time I'd been outside with him in a really long time. I started to approach a corner, and I saw that a bus was coming. All I wanted to do at that moment was to throw both of us in front of that bus, because I thought we'd be better off. I thought he'd be better off without me – this terrible mother who couldn’t live with such a big mistake. I don't know what held me back, but I did not do that. I remember the bus passing by; I caught a reflection of my face in the window and I thought “Who is that person? I don’t recognize her”. I knew that I undeniably needed help. As fate and luck would have it, I found myself being treated at the Payne Whitney women's clinic, which is the very clinic that Dr. Birndorf started. I started to heal and get better; I started therapy and I went on medication. I started to feel more connected to my son, and I started to enjoy motherhood as I was meant to.

When I got better – and when I can tell that so many other women at the clinic are on the road to recovery – was when I realized how common this experience was. I started speaking with so many other women who knew how I was feeling.  They said “Me too, me too”. That's when I took it to the legislative street -I started drafting legislation. Fast forward, we got our law. As you mentioned, our bill was signed into law  in 2014, and I was hooked. A few years later I joined forces with Dr. Birndorf and the original co-founder. Seven years ago we came together to create this amazing space that's been open for five years now. It’s the best thing that we ever did, and it's the hardest thing that we ever did – kind of like motherhood.

Aviva: Catherine, do you mind if I ask Paige a few questions about her experience before we jump in? Paige, during those six months, what kind of physical and psychological feelings and symptoms were you having? Did anybody around you notice or say anything?

Paige: I wasn't sleeping.  I wasn't eating.I felt anxious all the time. I always had cortisol racing through my body. I didn't feel connected or attached to my baby at all. I was going through the motions of caring for him, but I didn't feel anything towards him or for him. I had really dark thoughts of not wanting to be here anymore – not wanting to be alive. I had a hard time caring for myself, bathing, brushing my teeth, going outside. I wasn't finding any joy in anything that I used to enjoy. I felt hopeless. I couldn't make decisions. 

I know my husband knew that something was wrong; we actually did a really beautiful story together for NPR a couple of years ago, and it was amazing to hear him share his side of it in that moment. But he didn't know, either. He didn't know what was normal and what wasn't. There was one woman – a friend of ours – who came over to visit. She pulled aside and said “There's something really going on here”. That was right around the time that I decided I really needed to get care in order to stay alive. But other than that, nobody said anything – not my providers, not friends or family. I don't blame anybody, because this was 16 years ago. Well, I do blame providers a little bit –  we don't talk enough about it. This is where we see women fall through the cracks.

Aviva: I struggle with this a lot.  When I'm teaching pregnant people or even preconception people, it’s a balance between not wanting to scare them but at the same time knowing that, when we have the information, we have the knowledge and permission to get help. If we have symptoms of preeclampsia during pregnancy, somebody's looking for that, because we know it can be life threatening. Not enough people are looking for it postpartum, and that is when it's also life threatening. Even when these conditions are not life threatening, they're life disabling. They can be joy robbers of new motherhood.

With all the information we have around bonding, it’s a double whammy, right? You're experiencing all this horror, and then you're also worried that you're not bonding with your baby – that you're harming your baby in that way. When it comes to prenatal or early mom education, how much do you feel like we should be weaving this into the conversation of anticipatory care, along with nutrition and other things? 

Catherine: Can we start in grade school?

Aviva: I'm with you.

Catherine: I'm not joking, even though we're laughing. We need to be talking about this as if it’s typical. There's a word, “matrescence”, which means becoming a mother. It's not a developmental stage per se, because it doesn't apply to everybody. Not everybody goes through it. I think that in that journey, it is typical. Again, I hesitate to use the word normal, but it is normal but to feel ambivalent – to feel challenged and to know that it’s confusing. You know, all the emotions – a full spectrum of emotions. When you think back to the childhood books we read, or to the stories that we've been told and the movies we’ve watched, what we see is that it's just beautiful and easy.

Moms and women who don't like kids – don't feel bonded to their children, who struggle – are sometimes considered monsters. That's so unfair. It's so not right. There are so many different ways to feel. That is normal. That is typical. Because we only allow it to be a certain way, we don't have that opportunity. We could be teaching that at an incredibly young age, if we could just open that door. You asked the question, how much do you say in a prenatal visit? I've been up against this since I started my training in the early 90s. They didn't want us to go into the hospital. I would say, “Can I come talk to your moms about postpartum issues?” and they'd say “What do you mean? What are you going to say? You're going to scare them”. I was like, “I'm really not. I'm going to speak about the spectrum of feelings that women can have, or families can have”. They really made it hard – The establishment, even the nurses who ran this program. They were nervous to have me come in and speak about postpartum illness because of what it was going to do to the patients or to the prospective parents. It’s so unhelpful to not tell anybody the truth.

Aviva: My book came out in 2000, which means that I was writing it in ‘98. Now thinking back, it was ahead of its time. I had a midwifery client who came in with her second pregnancy. She had experienced six years of deep postpartum depression – it was a PTSD situation from a birth trauma. Interestingly, she had had a homebirth and had to transfer to the hospital because of a hemorrhage. Midwifery was illegal in the state that she was living in, so the midwives put her in the car and sent her to the hospital with her husband. She felt desperately abandoned. On top of it, she had a postpartum thyroid problem, so she had had heavy bleeding. 

She had so many reasons for being at risk for postpartum depression, but it was clear when she came to me that no one had noticed the symptoms in her for two years. She lived with two years of hell. That was when I started to dig in –  to actually print out articles from the medical library. There wasn't that much available, but there was some work There was Dana Raphael's work, some work on doulas and the importance of female care and birth, and some work on postpartum depression. What's crazy to me is that ‘ve been through seven years of medical education – three years of that  with a focus on obstetrics in family medicine – and many years of midwifery. There was no training in any of that on postpartum, and the prenatal anxiety and postpartum anxiety are certainly newer. Catherine, you were ahead of your time as well with setting up the clinic and getting into the work around postpartum depression and PMADs. What inspired you?

Catherine: Your story is so resonant – mine is not so different. My story begins long ago, when I was at Smith, an all women's college. I loved always having the woman's perspective incorporated into all classes – I thought they did it so brilliantly. That was just part of the culture. I became very interested in reproductive rights, and I thought I was going to go that route professionally. When I found that I wasn't qualified to get a job working in policy after college, I ended up working in a women's health center. It was  essentially an abortion clinic in a halfway house. I lived there two nights a week  and helped to provide mental health care. It was a really progressive place in Washington, DC – it was amazing. 

All of that informed where I was heading. I didn't know I was going to end up in med school, but I found myself there. I was feeling like the women that I saw around me were doing the coolest things, but were not getting the respect they deserved because they didn't have the MDs. I don't know if you’ve had that experience, Aviva.

Aviva: That’s why I went to medical school. I was happily practicing as a home birth midwife, but I was in an illegal state, which also happened to have (and still has) the highest maternal and infant mortality rates in the country. I felt really powerless to do anything, because my voice as a home birth midwife was entirely invisible. I even tried to involve the Atlanta University black family health project – got a board together to try to create a MOMobile to go into high risk communities. This was in 1986, and I was told I couldn’t do it. “You're an illegal midwife – you guys don't count here.” So for me, it was really about having the credentials and the credibility to make a change – exactly the same thing that you're talking about.

Catherine: I would've come to work for you if that was happening. That's incredible. It’s sort of the same – I thought to myself, “Well, if I'm going to go this route, I might as well go big.” I had to go back to school and do my post back – my premed. When I ended up in medical school, I really thought I was going to be an OBGYN.  I worked with midwives. I was at Brown, and all the babies I delivered in med school were with the midwives, which was so cool. I got to psychiatry and I figured out what I wanted to do – it blew my mind. I thought, “You know, I can get to women's mental health in a variety of ways, and this seems to be a better fit for me.”

I was always committed to the intersection of OBGYN and psychiatry.  I got into the field when I was in my residency. I had my first kid, got pregnant in my third year, and delivered in my fourth year. I'll never forget how incompetent I felt.  I left maternity leave early to get back to work. I got eight weeks, because I had a C-section – you get six weeks for a vaginal delivery, and eight weeks if you had a C-section. I remember at week seven thinking, “I'm losing my mind. I don't know what to do with this kid. I'm totally incompetent. I think I'm making things worse, and I better get back to work where I know how to be successful.” It wasn't going that well at home. My husband is also a physician, and he was in his research years. The two of us were looking at each other like ding dongs, and didn't know where to get help or what to do. So I think that my personal story started there – it was really hard to be a new mom.

Aviva: It  brings you to your knees, no matter what competencies you have in your life. Sometimes I think the women I work with who have a significant amount of external competencies are cognitively challenged by the transition. Suddenly they’re thinking, “I don't even know how to change a diaper or make this baby stop crying. Are they starving? What's happening here?”

Catherine: I was always pushing, always asking for more. “Hey, can I go over to observe at OBGYN and talk to the patients?” Nobody was doing it. I also ended up in Chicago during my second year of residency, because my boyfriend at the time (who is now my husband) was at University of Chicago studying surgery. I went there for my second year so that we could be in the same place, and I ended up getting myself a position in a residency program for that year. 

I worked with Laura Miller, who’s one of the foremost experts in the field. She had a unit that I wanted to work on for psychotic, pregnant, addicted women. They didn't have it in New York, so it turned out that the year I went to Chicago, I actually got the most robust trading of my residency. When I came back, I was on fire. I was like, “How do I get this? How do I find this? How do we create this? Why isn't this happening?” There were a few people doing it, but they were kind of in their own silos; there was nothing organized. When I started the women's program, I went back to Chicago with my husband to finish and apprentice there with a colleague at Northwestern. When I came back to New York, there were six or so seminal articles on the topic of meds in pregnancy.

I remember when I started the program – I was like, “Here's your little packet of what we know. Here's the definitive work in the field, and it's not particularly definitive.” I was adamant that we were going to help these women – to sit with them, trying to understand their individual positions and why they were struggling. I tapped everyone I ever knew in the field and asked them for their help. I asked them what they did, how they pushed forward.  I really stand on the shoulders of many before me who helped to create this field of reproductive psychiatry, or perinatal psychiatry. It didn't even have a name back then. 

Aviva: Now most women go to their OBs. Some women go to their midwives. In conventional medicine, we don’t start postpartum care until eight weeks postpartum. Most people don't get sent to a perinatal psychiatrist or psychologist, and most OBs – well, it's not just OBs. Pediatricians, family, doctors, midwives, postpartum doulas – all the people involved in the care either don't know what to look for, or don't know the questions to ask. Even if they do see something, they don't know what to do. Unfortunately, the onus is on the pregnant or birthing person to recognize what signs and symptoms to look out for. 

Paige: There's a couple of things that I want to say. You've made some really important points here. The truth is, I’m coming off of the coattails of a three day conference. I was with a whole bunch of perinatal mental health specialists in New Orleans, and you're right. OBGYNs, pediatricians, and other providers that come in contact with new and expecting mothers are not talking about or screening for PMADs. Where does that leave us? That leaves the onus on a new or expecting mother who's already struggling, who's drowning in a sea and paddling as fast and as hard as she can to keep her head above water. I speak from experience when I saw that the last thing she is able to do is pick up the phone and start trying to find help for herself.

We need to move in the direction of making it mandatory for OBGYNs, midwives, pediatricians, and all of the other providers who come in contact with a new or expecting mother, to start talking about PMADS. Education is prevention. We need to be screening for PMADs – not just once.  I would go so far as to say every three months. PMADs need to be a part of every visit, every conversation, because that's where we start to break down the stigma and the barriers. We give women permission to feel this way and ask for help. That is one of the only ways we're going to be able to fight the statistic of 80% of all new and expecting mothers falling through the cracks. Now I’m going to pass it over to Dr. Birndorf to talk to you a little bit more about the actual signs and symptoms.

Aviva: Amen, sister. I could totally get behind working together to make that requirement a reality.

Catherine: Yes – back to basics. I want to make the point that just because depression, anxiety, PTSD, OCD, and psychosis are happening during the perinatal period, it doesn’t mean that it’s causal.  It's just the timeframe. They're happening in the context of the hormonal storm, yes, but we don't know if that’s the cause. That is a stressor; it is part of it, but it is not the whole story. People see pregnant or postpartum women and they're like, “I don't know what to do. I can't touch that patient. We can't do research on these people because they're so fragile and different.” That's a problem.

Aviva: We're living through a mental health epidemic where one in four women is on an antidepressant or on an anti-anxiety medication. As you say, this may just be something that exacerbates an underlying condition or is part of a bigger cultural milieu.

Catherine: There's lots to say about what you just said, but first I want to get back to basics. I go back to med school asking, “What is depression?”  don't know if you remember SIG-E-CAPS: It's an acronym for depression screening that all of us medical students had to memorize.

Aviva: We have so many acronyms.

Catherine: So many acronyms! But it’s about sleep interest. G is guilt; E is energy; C is concentration; A is appetite; P is Psychomotor –  retardation or agitation. 

Aviva: For people who don't know, retardation and agitation means slow movement and irritable movement, respectively.

Catherine: Thank you for the translation. What I want to point out is that people go to their doctor, midwife,  or providor during pregnancy or afterwards, and they say, “I don't feel great. I'm not sleeping well or eating well. I can't concentrate. I don’t have my usual energy.” Those are the first four symptoms of depression. It gets confusing, because people will write you off and say, “Oh, you're fine. Everybody feels that way.” But what Paige was describing is never normal – hopelessness, guilt, feeling like you don't want to be here anymore, not enjoying things. None of that is normal. Hopelessness, helplessness, guilt, and suicidality are never normal. You don't always know to ask those things or to tell those things during your postpartum visit or your prenatal visit, so they could easily be overlooked.

Aviva: What about the anxiety symptoms?

Catherine: Again, the anxiety symptoms come in the form of apprehension, dread, fear, and avoidance. With a panic disorder you have elevated heart rate, sweating, and sympathetic responses. You feel like you're going to go crazy or die. They crescendo and decrescendo quickly. You can have OCD type symptoms, which have been kicked out of the anxiety disorders category, but we still think of them that way. You have thoughts that you can't get out of your head, or compulsive actions like washing, checking, counting, cleaning, evening things up, touching specific things – sort of magical thinking that revolves around ways you can neutralize the anxiety that you feel. That can take up lots of time in the day, and to some extent can also lead towards a loss of touch with reality. We also have PTSD, which is a re-experiencing of trauma. The trauma can be from birth or from other events in the past. You experience the traumatic event or events again and again, or you have hyper arousal. Those are the basics.

Paige: I want to throw in two more, one of which I feel is important because it happens to so many women. Every time I say this to a crowd, people are like, “Oh my God. I'm so glad you said that. That happens to me, and I didn't know it was something that 80% of all women experience.” Scary, intrusive thoughts that are very distressing and disturbing. Sometimes graphic thought images will pop into a new mother's head, and she can’t get rid of them.

Catherine: Horrific thoughts about hurting the baby, throwing the baby. Terrifying stuff.

Paige: A new mom cannot get rid of these thoughts – they keep happening. Thoughts about putting the baby in the microwave, throwing the baby down the stairs, throwing the baby out of the window, pushing a stroller into traffic. You name it. These thoughts just pop into her head. and she is petrified. Oftentimes they get in the way of her actually going into the kitchen, leaving the house, getting close to windows, or even walking down the stairs. There is an OCD flavor to it, and 80% of all new mothers have these thoughts. They're so disturbing that we don’t talk about them; we keep them inside, and feel terrible. What kind of mother would think this way about her baby? Well, 80% of all new mothers would have those thoughts. 

The other thing  I want to say falls into the category of birth trauma – PTSD is birth trauma. It happens so frequently. Because birth, for all intents and purposes, can be such a beautiful experience, that’s often the only way we're conditioned to speak of it. But so many women experience a traumatic birth. As Dr. Birndorf always says, trauma is in the eye of the beholder. It doesn't matter if, as a listener, you think it's traumatic or not. It's about how that person experienced it. Birth trauma can lead to all kinds of PTSD symptoms,  and so many women experience some level of birth trauma that can be really activated in the postpartum period. It can oftentimes be seen in concert with some of those other symptoms.

Aviva: It can be triggered by breastfeeding or hearing the baby cry – by the relationship with the baby in general. The data I read most recently says that 7% to 14% of women experience birth trauma, and up to several percent could be diagnosed with PTSD based on their birth experience. That's a really high percentage.

Catherine: I thought the number was actually a little bit higher.

Aviva: It may have gone up since the pandemic, which I want to ask you about. Again, when I was writing my book many, many years ago, there was much more anthropological data than there was actual data, and anthropological data can be romanticized. We know that there's dramatic under reporting, and at that time, the conversation was primarily around postpartum depression. It does seem that in many cultures – especially ones where people live in community, or more traditional foreign cultures –  perinatal anxiety and depression, and especially postpartum depression are not much of a thing. I'm curious to hear your thoughts on that.  

Paige: We've all heard the term “it takes a village”, right? Sometimes we've heard it so often that it's lost its meaning, but we revive it all the time because it's such a powerful statement. It is so true. When we look back anthropologically at families and family systems, we see that there were much more expansive units of family members – cousins, aunts, and uncles around to help new moms. Many, many years ago, there were many family members eating at the same time, so the baby was passed around. It was really a family affair. Fast forward to contemporary society: even in the best of times, parenting is a very isolating and lonely experience. 

You take a place like New York, which is where we are, and I can speak for myself. My parents are in California. My husband’s parents are in Germany. We don't have any family members here with us – it's just us. This doesn't even begin to talk about the experience of single mothers who don't have that family network and social support system in place to help them transition to motherhood. They are alone and isolated by design. Add a pandemic to that scenario, and you’ll understand why we have never seen rates of mental illness so high across the board, and in our particular area in regards to PMADs, That lack of social support is even more sparse; the isolation is even more profound. High levels of stress and anxiety are a direct result of an international pandemic, a pandemic that is life threatening to a pregnant person or a new mother, whose sole purpose is to keep her infant baby safe and healthy. You bring all of that into the room, and it's no wonder that we've been seeing these skyrocketing rates of depression and anxiety in the perinatal period.

Aviva: What kind of rates have we seen since the pandemic? I heard a statistic that said there has been a 70% increase in perinatal mental health symptoms and conditions. Is that about right?

Catherine: Yes. I don't have the statistics off the top of my head, but a study at the Harvard school of public health showed that there was an astronomical increase. I think Paige and I usually quote around a 72% increase in rates of anxiety and depression during the pandemic. That’s the top end of the range, but what we know is that we have all been so fundamentally changed during this never ending pandemic that rates of everything seem to be having an uptick. 

I don't know where we're going to land or how it's going to go, but I would say that there is most certainly a maternal mental health crisis happening. It’s evident in the number of calls that we're getting at the center; in the rates of admission to our programs, both our outpatient program and our perinatal day program. As I sit here now, I'm getting a call about another emergency. There are emergencies happening daily in ways that we have never seen before. People are unhinged – that's a colloquial word that everyone can understand. What we're seeing with pregnant and postpartum women is profound. We're dancing as fast as we can to keep up with the need, but there is so much more that we could be doing. Everyone in our field is trying to meet the needs, to be ahead of it. To have the places for people  to go, knowing that crises are on the horizon. I don't mean to be so negative, but on the other hand, I feel like there is so much that we know, and there is so much we can do. You can medicate pregnant women and those who are breastfeeding. We have tons of data on that, and it's relative safety, yet people are still wondering, “Do I have to go off my medications because I'm pregnant?” Well, if you're bipolar and you go off your meds, you're likely going to end up in the hospital. Does that seem like the better way?

Aviva: Back to this issue of being negative – I think that our culture has such a toxic positivity that if we talk about the truth, then we're somehow seen as negative. I apologize for it too. There's a liberation in knowing that we're not alone.

I've told this story before, because sometimes people look at someone like me, or other people who are out there in the public, and think that we have it all together. I remember being pregnant with my third kid and trying to get my oldest two off to a playdate at the park. It was like a cartoon strip of a mom escalating and escalating just to try to get the kids to put their shoes on, trying to go do something fun with the kids. I was emotional.I had this empty plastic Tupperware in my hands, and I took it and threw it on the ground. It bounced up to the ceiling and the kids were like, “Oh shoot – Mom's really upset.” They got their shoes on and we got to the park. I was a midwife at this time, and the other moms in the mom group looked up to me. I sat down, and the moms were sharing all their happy stories. Someone said, “How's it going, Aviva?” I was like, “Well, you know, I did throw the Tupperware at the ground this morning in lieu of throwing it at  someone.” There was this moment of time standing still, and then it was like time fast forwarded. All the moms started talking about what was really going on. 

When we say 72%, is that negative? No, it's, it's real. If you're a mom out there listening and you're hearing that number, I hope you're going, “It's not just me.” This is almost three quarters of all mamas. It doesn't make it better, but maybe it makes it feel a little less shameful. I want to keep emphasizing that it's a cultural phenomenon; it's how we live. There are known biochemical shifts and hormonal things happening. There are also unknown biochemical shifts happening. You're not alone. It's not you. Stop apologizing.

Paige: What you’re talking about is permission, right? We are normalizing it by sharing our truth and telling our stories, and giving other women permission to do the same.

Aviva: Catherine, I know you have some emergencies coming in, so I want to be respectful of time and what's going on for you. If you have a few more minutes, I'd really like to talk about medications. Paige, you mentioned medications being transformative for you, and Gabby Bernstein has been public about her work with you. I've spoken with her. I was there for her postpartum support, and I know how liberating medications can be, but they're incredibly stigmatized. In my online community, there's often a leaning into natural medicine, so there may be an even higher level of stigma around medications. I'm very supportive of their use prenatally and postpartum. We know from substantial data, at least in non-pregnant people, that combining medications with therapies like CBT can actually improve their efficacy and outcome. Can you talk about the role of medications, and the importance of giving women permission to explore them?

Catherine: This is my favorite topic, because we used to think that it was the mother or the baby – that it was an either/or situation. But if you have some kind of mental illness, from mild depression to more severe psychosis, you are at risk. You have to accept that if there's illness, there's risk, and you're weighing that against the medication – the potential risk of the medication versus the potential risk of the symptoms or the illness. No decision is risk free. People think, “I'll just sacrifice. I'll suck it up and stay home. I’ll never leave my house and I won’t go for prenatal care. Someone will give me something natural over the counter. I'll get it at the drugstore. Maybe I'll even smoke marijuana, because that calms me down.” But won’t take the FDA approved medications that are relatively safe and have been very well studied – probably more studied than any other category of medication that we know – because they think that those will harm the baby. What they don't realize is that they're potentially harming the baby in a million and one other ways that they are not considering, because they are not taking care of themselves. If you are not okay, and you are not well, you are not helping your pregnancy or the fetus. You are not helping your baby or child.

Aviva: Yes, we don't have to suffer. In my work, I'll make sure their thyroid is normal. I'll make sure they're not anemic. I'll make sure vitamin B12 vitamin and Vitamin D levels are normal. I’ll make sure there's social support. I may try botanicals, and other things. However, if I’m trying these things for weeks and weeks, they’re losing a lot of time. We all appeal to moms to do things, because it's better for the baby, but it’s also better for your memories and experience of pregnancy and postpartum – experiences that in and of themselves can cause you ongoing trauma. I'm a big fan of giving ourselves permission to not suffer and to not be miserable.

Catherine: Amen. I’d like to add that it might not even be medication that helps. It might be psychotherapy. We try everything in addition to, or before medications. If we don't need to use them, we don’t, but obviously by the time a pregnant or prenatal woman gets to a psychiatrist like me, there’s a high chance we might be introducing medication. We don't do it against anybody's will – we always do it in conjunction with the mom and the family. We give it a lot of thought, but sometimes it is a big part of the answer.

Aviva: I’m encouraging all of you listening to at least keep it in your toolkit of things that you would consider. Paige, you have said that it was like a life and death situation for you.

Paige: I mean, it was my life preserver. For those who come and learn more about The Motherhood Center, you'll see that our logo is a life preserver – not just because of medication, but because of treatment overall. For me, medication made all the difference. Of the thousands and thousands of women that we've treated, many of them who have taken medication continue to take it during pregnancy and in postpartum. Medication is life changing. It is a life preserver that will allow you to have the experience of motherhood that you have always wanted to have – to get back to your baseline and feel good. As we always say to pediatricians and other providers, a well mom is a well baby. That's when you can actually show up, be present, and have the experience and bonded attachment that you always hoped for.

Aviva: I'm going to ask each of you one quick question before we wrap up. If there was one thing you could each tell your younger self, perhaps your pregnant or new mother self, what would that be? Paige, do you want to go first?

Paige: I would perhaps steal some of the slogan of Postpartum Support International. You're not alone – this isn't your fault, and you can and will get better with the right support.

Catherine: Ditto. I would tell my younger self, “Be honest with yourself. Admit that you're having a hard time and tell somebody. Ask for help. Don't just try to shoulder it all.” That’s my M.O., and I didn't have to. I didn't have to be having such a hard time; nobody needs to be struggling alone. There are so many things and people out there – community to help hold you. We can do it together.

Aviva: You two are so beautiful. Thank you for being here. For those listening who want to reach out to you and The Motherhood Center, what are the best ways to do that?

Paige: They can give us a call at 212-335-0034. They can visit our website at www.the motherhood center.com. We offer support groups, outpatient treatment, inpatient therapy and medication management with reproductive psychiatrists and perinatal mental health experts. We also have a day program, which is a more intensive level of care for new and expecting mothers that are having a really hard time caring for themselves and/or their baby. We are serving all of New York state and New Jersey, and we're looking to expand. Even if you're out of state and are curious to learn more, you can give us a call and we'll help connect you to the care you need wherever you live. Please, please reach out. Call us. If you're struggling, we wanna help get you back on the path towards enjoying motherhood as you want to – the way you’re meant to.

Aviva: We're going to put the links to all of the things in the show notes, so you can find those folks over at www.avivaromm.com/174. Thank you both for joining me. As always, it's been such a pleasure to talk with you. I hope that we do some collaborative things. Stay in touch, and I  wish you both so much goodness in everything in your lives. Thanks for all of the goodness you're bringing to mamas, as well as pregnant and birthing people.

Paige: Thank you so much, Aviva. It was a pleasure to be here. Thanks for giving us the opportunity to talk about something that's so important.