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Sarah Juul, M.D., MSc.

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New Mothers Need More Than Medication

Posted: 11/20/2013 11:37 am

Pregnant? Here's a prescription.

Today is my son's second birthday. Two years ago today I was handed a 9.5-pound swaddled bundle of... not joy, exactly. My first words when my mother came to see me in labor and delivery were, "Why would you ever do this again?" I was numb with the shock of childbirth and already felt overwhelmed with the demands of a new baby.

Two years later, I know I'm in good company. As a perinatal psychiatrist, I see new mothers every day who struggle with this emotion-laden rite of passage. Women admit their feelings with tremendous guilt in my office, as though they are the first ones to feel this way. They feel shamed, scorned and think they have already failed in their tentative beginnings as mothers. "Why don't I feel like the glowing, happy women on the cover of magazines?" one woman bemoaned.

New mothers often describe the experience of being swept into a sea of new and old feelings and fantasies: buyer's remorse for a demanding wailing newborn, childlike needs to be soothed and mothered themselves, violent imagery of harm coming to their babies. The newly delivered baby sometimes seems like a stranger, even alien.

With a positive pregnancy test, we get a narrow script for how to feel. It reads like a one-dimensional romance novel: an adoring mother with only room for warm, loving feelings for her new miracle child.

All too often, modern psychiatry also fails to recognize the meaning behind the essentially human experience of pregnancy and early motherhood, a time of tremendous and expected psychological flux. Bearing prescription pads, many psychiatrists think a pill is all we have to offer, our knee-jerk reaction to any emotional intensity.

Recently, a first-time mom was referred for an evaluation by her obstetrician. Alone at home with a newborn while her husband was away for work, she described how, in a fit of utter frustration with a colicky baby, she threw her cell phone against the wall, shattering the face of the phone. A young physician calmly described her diagnosis and treatment plan: the patient suffered from an impulse control disorder and would need to be started on an antidepressant for treatment. A colleague laughed at this story. "But that's great coping," he quipped. "She didn't throw the baby!"

In fact, women across ethnic and socioeconomic groups report a clear preference for psychosocial over pharmacologic treatments in pregnancy. Those with the means and opportunity can benefit from psychotherapy as an alternative to medication.

There is convincing data that psychotherapy works at least as well as medications for mild-to-moderate depression and anxiety and may have lasting benefits that even grow with time, unlike medications. In the U.K., psychotherapy is a first-line treatment for these conditions, not medications. However, psychotherapy in this country is a limited commodity, with virtually no services for lower socioeconomic and underserved populations, and tightly regulated
services within insurance plans.

Psychotherapy can help women become more attuned to their own feelings and those of their babies. The process allows for exploration of emotions, in contrast to a prescription, which may send the message that feelings are problematic and need to be swallowed, rather than voiced.

There is tremendous importance in a mother's understanding of her own emotional mind. Pregnant women with a well-formed imagination of their baby in-utero have been found to be less likely to develop depression. Simply having a fantasy about your baby's burgeoning personhood may promote a more secure attachment postpartum.

Babies also learn about their own emotions through their interactions with their primary caregiver. A baby's raw emotions are received by their caregiver and then reflected back in a digestible form. "You're angry because you're so hungry," a new mother coos to a crying baby before feeding her, allowing the baby the experience of knowing that her emotion was effectively communicated and responded to. For a mother who is overwhelmed by these emotions, this crucial process is disrupted.

Medications certainly have their place and must be a part of a treatment plan when a woman is suffering with severe symptoms of depression, particularly when there is a risk of danger to herself or to her baby. It has to also be acknowledged that these narrow standards for our emotional lives are not unique to the transition to motherhood.

And it's not just psychiatrists who pathologize discordant emotions. It also happens on societal, interpersonal and internal levels. At best, we make a joke of the frustrations of pregnancy and motherhood, but this lacks the resonance of a full open acknowledgement. The psychiatric community, however, has the responsibility to recognize that emotional experience is varied and deep, and that not all problems need pills.

 
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