Courtney Collen (Host): Hello and welcome to “Her Kind of Healthy,” a health podcast series brought to you by Sanford Women’s. I’m your host Courtney Collen with Sanford Health News. We want to start new conversations about age-old topics from fertility to managing stress, healthy living, and so much more. “Her Kind of Healthy” is designed to bring you honest conversations about self-care, happiness, your overall well-being with our Sanford Health experts.
This episode, we are focusing on the topic of postpartum depression.
I am fortunate to have Karla Salem for another great conversation. She is a certified social worker here at Sanford who specializes in women’s health. With over 22 years at Sanford Health, Karla has cared for more than 25,000 women pregnant or postpartum. Her expertise in this space has answered many of my frequently asked questions. Karla, welcome.
Karla Salem: Oh, thank you so much. It’s an honor to be here, and I really feel like the women that have taught me over the years how they feel and what that looks like, I feel like this is dedicated to them.
Courtney Collen (Host):
Love it. And full transparency, as we’re recording this, I am beginning my third trimester of pregnancy. So on a personal note, I know I’m about to learn a lot from this conversation, and I hope you, our listeners, find value as well.
Karla, we’re so glad you’re here. I read a lot about new moms experiencing the baby blues after childbirth. That rush of hormones, emotions. I want to start off talking about this idea of baby blues and distinguishing between what often comes in early postpartum and when that takes a turn to become something that needs more care and support like postpartum depression.
Karla Salem: Well, that’s a great question because distinguishing me between the two is sometimes hard for women to understand as you’re verbally explaining it before delivery. But after delivery, they go, ‘Oh my gosh, yes, I do understand that difference’.
So blues happens to about 80% of all women, and it happens about two to three weeks postpartum, after delivery. It’s kind of a combination of hormonal activity, kind of playing around, going back where it belongs, and then sleep deprivation. Sleep deprivation is a huge, huge component. And folks who have never gotten more than two to three hours of consecutive sleep for three weeks, we’ll notice that, that they’re greatly impacted by that.
Courtney Collen (Host):
What is physiologically happening in the brain that would lead to a diagnosis of, say, postpartum depression?
Well, almost all anxiety and depression has three components: a biological component, a psychological component, and a social component. So understanding the biology becomes very, very important because things have happened to women’s brains during this time.
So, we have serotonin, which manages our mood. And when it’s most effective, it’s very buoyant or bouncy between our neurotransmitters. When you have a baby, it flattens like a pancake. Its primary job is to offer energy. It offers mood control. And it also holds down norepinephrine, which is our anxiety neurotransmitters.
So when serotonin flattens out after having a baby, we have nothing really to hold down the norepinephrine. So you have both a combination of kind of moodiness off and on, irritability for no reason, crying for no reason, plus just this kind of intense anxiety or overthinking, or busy-brainness that also occurs.
And the deal with anxiety is when all new moms start to have, you know, safety thoughts, safety thoughts they’ve never had before, all of a sudden, they enter a room, they look at where the outlets are, they look at, you know, what could be a problem. And so that’s very, very normal.
But norepinephrine, anxiety, overabundance of norepinephrine will take that little startle or that little thought, that little safety thought, and all of a sudden, they can see the whole big picture, a gruesome ending, and somehow they’re inserted in the whole process. So very scary. Like, I’m going down there, or I’m passing the stairs with my baby. Oh, I hope I don’t fall down. What if I fall down? Suddenly, you see yourself at the bottom of the stairs with your baby and all of that, even though cognitively folks know it’s irrational, the anxiety, the chemical change, the biological portion makes it so they’re unable to let go of the thought.
And then they go on to another thought. And it’s so interesting because there’s such common safety thoughts that go this direction. The stairs, bathing the baby, putting children in cars, and what could happen, being alone for the first time, and who might come into your home. Those are all so common as safety thoughts that when I mention them to women, they’ll go, ‘Oh my gosh, how do you know?’ And because many other people have had those same situations, it just is a little bit of a comfort to know they’re normal in the thinking that they’re having.
Courtney Collen (Host): And how long would these feelings last? Whether it is the, like we said at the beginning, the baby blues, the anxiety, or the depression … What kind of a timeline are we looking at?
Karla Salem: Blues occurs for just that two to three weeks. And it’s like crying for absolutely no reason. Like you see a leaf blow and oh my gosh, you start crying. And it mostly becomes an issue for both the patient because they don’t know why they’re crying and their partner or their support people who will say, ‘what are you crying for?’ And they don’t know what they’re crying for and there’s no way to fix it. But it has a pretty short life, especially if people get some sleep in the first two to three weeks. And what people will find, what women will report is, ‘I slept a little bit, I feel so much better’ and that was probably it.
The chemical change that happens with serotonin and norepinephrine after having a baby actually takes two years to restore. So it takes about a two-year period of time, which is always just a phenomenal, interesting idea for people because they think everything should be very immediate and should go back to normal.
Women can notice increased anxiety you know, right after having a baby, they can notice it gets more intense when they’re starting to go back to work or their support people are no longer there. They can even notice it – if they’re breastfeeding – when they stop breastfeeding. So they’ll say, you know, 12 months later, ‘I don’t even know what’s wrong. I don’t know why I’m so anxious,’ but their brain is still trying to restore from having a child.
Courtney Collen (Host): So knowing that a lot of this has to do with that chemical balance in the brain or imbalance postpartum, can postpartum anxiety or depression be prevented beforehand? Is that even possible?
Karla Salem: Well, most folks don’t want to do that. I mean unless they have been through it before. If it’s your, if it’s a second or third baby and people have a history, they know what’s going to happen. They will go oftentimes go on an antidepressant to start restoring those chemicals before they have a baby. Or they start right at the time of having a baby. New moms really want to experience, they want to know what’s going to happen. And so they kind of have to experience it.
But it’s something that’s so easy to educate women on. This is what you’re going to be looking for when you don’t feel like yourself anymore. When you feel like you are, you know, your mouth is yelling at somebody and your brain is going, why are you doing that? When there’s a disconnect, when you know something is irrational, but you can’t stop thinking about it. Those are the kind of the signs and symptoms after about two weeks that you want to address.
And so oftentimes women will come on their own because they don’t feel like themselves. Support people, either a partner or a family member says, ‘I think maybe you need to go talk to somebody.’ And usually once folks find out about this chemical piece, they really are so relieved and anxious to look for solutions, whether they be behavioral, cognitive, or medication.
Courtney Collen (Host): When might a woman first experience that first sign of anxiety or postpartum depression? And when is it time to see a provider?
Karla Salem: The first signs can build up, like, you can have an episode, but it goes away. And so, ‘well, that was probably because I’m overwhelmed or that was probably because of this and that’. I mean, we as humans are good at explaining away things. And so, it’s usually a little bit of a more of a cumulative kind of experience. Like over a period of time they notice that they’re just not themselves. They’re more worried than they’ve ever been before. And coping mechanisms that they’ve always used are just no longer as effective as they used to be.
The thing about anxiety is very odd because a lot of people experience anxiety throughout their life. We are born with our brain chemistry. So, if our brain was busy at one point in time, it’s busy now, but we learn so many coping mechanisms on how to deal with that busy brain, how to distract ourself, how to replace thoughts, that it doesn’t really become an issue. But after having a baby and having an actual chemistry change, all of a sudden, it’s more intense than it ever has been. The solutions, the distractions, all of that, none of them are working the way they used to. And it becomes just confounding for women. I have more women that say, ‘well, I probably have always had a little bit of anxiety. I’m kind of a type A person’ which is usually pretty much code for managed anxiety. ‘But now this is ridiculous. This is, you know, I used to work out and that doesn’t help me anymore. I used to go see friends and now I don’t want to go anywhere.’ And so, all of those things that used to be normal are no longer normalized because of that biological connection.
It is interesting though, when we’re looking at depression and anxiety postpartum, there’s three kinds of variables that people look at as precursors. And one is a history of depression or anxiety. The first is a personal history. The second is a family history of depression or anxiety. And the third, which it just always just knocks me out, is a woman’s perception of how much support and assistance that they have postpartum. So, and it’s perceptual. It’s not what is or isn’t, it’s perceptual.
So if a woman feels like they must do everything themselves, they don’t allow anybody else to do anything, they restrict visitors, their partners are limited as to what they’re allowed to do. That can be an important and controllable factor in whether or not someone develops anxiety or depression postpartum. So, it’s always fun to talk to women about sharing their baby – not pawning their baby off, not accepting responsibility – but sharing, allowing people that they trust and love to start having a relationship with their baby. And at the same time, giving them some downtime from being overly stimulated by that child and all the responsibilities that it brings.
Courtney Collen (Host): This is so interesting when we talk about those first signs or maybe precursors to potential diagnosis or needing care. Let’s talk about finding support at Sanford Health. What does that look like? When does an expert like you step in or that, when is that connection made postpartum?
Karla Salem: There are a lot of points that people get to kind of have a baseline during pregnancy. There are some screenings done regarding depression levels or anxiety levels and also about past trauma. Oftentimes having a baby is such an invasive kind of procedure. You know, privacy isn’t there very much. I mean, it’s just a physical exposure. Oftentimes women who have been assaulted in their past, this starts to bring back memories that some didn’t even know they had. And so that becomes an important question during pregnancy and postpartum, just because you want to make people as comfortable as they can be postpartum and enjoy their baby.
And so, understanding that concept that that could come back, you know, because trauma stores and when it’s triggered, it comes back bigger and more ferocious. So, we try to make sure that we’re doing screenings throughout the pregnancy.
Then postpartum our midwives have always done a two-week visit, but there’s a well-baby visit and they do a postpartum check on mom’s emotional check well-being. And then – those patients that want to go back to their OB/GYN, they’re offered also a two-week visit. So, that two-week time is when you know if things are not getting better. That’s when you can kind of figure that out, and then if the patient wants to speak to somebody, we get them into somebody not for therapy so much, but just for explanations and then not only what just happened to your brain, but also what you can do to help yourself and then what you can kind of monitor to make sure that the symptoms don’t get worse and then what that next step would be.
Courtney Collen (Host): OK. Great information. And what might treatment look like for anxiety, depression, postpartum?
Karla Salem: Well and there’s a whole continuum, you know, for a lot of folks, it kind of depends on what time of year you have your child, April through August in South Dakota are our sunniest, longest daylight days. So, serotonin reacts to that. Our retina exposure to sunlight increases our serotonin. So usually April through August. And honestly, there are exceptions. There’ll be people who will always tell me, ‘But I love the winter. That’s when I feel the best. I get uneasy during the summer’. But mostly we tend to have more energy, be more hopeful, get outdoors, have more exercise in those months.
If you have a baby in September, October, November, we’re coming into a season where the days are very short and become even shorter, which also does affect how fast your serotonin restores. I talk to a lot of folks who’ve had differences even in themselves having children in April or May versus having them in the fall or winter. So, I mean, that’s kind of one thing that you kind of want to look at. So, it’s just one another factor.
Some women just want to talk to somebody and they’ll go into some kind of a solution-based therapist where you look at what’s going on right now, what can we do, what plan can we put together? You stick together a treatment plan and then monitor that periodically.
Other women have some real like family of origin issues. They have some real issues that have been now exacerbated by having a baby. And they’ll go into more prolonged therapy, they’ll go to a therapist, meet with them weekly, every other week. And that’s the treatment they have decided. Some women will decide on more of a pharmaceutical solution. And with that they will get education regarding SSRI antidepressants or selective serotonin reuptake inhibitors. And they will work with their doctor as far as starting that and then monitoring the medication to see what it’s doing and how it’s helping.
A lot of women will go into more behavioral plans, especially folks who don’t really want to go on medication. They will lower their guard and let more people into their life. So they will have people that they trust, you know, come in three times, planned three times a week, just so that they have time to do something else and or they have more exposure to other people. They’ll make a plan with their partners as far as sleep, how to increase their sleep. They’ll make a plan to, especially at their home every day when their partners get home, to be able to leave their home and see something else just to experience something other than their home. And those are all behavioral plans that can be part of treatment to deal with it.
Courtney Collen (Host): You brought up partner or spouse, significant other, whatever it may be at home. We focus a lot on the new mom in this conversation. But can dad or partner, significant other, also experience effects of postpartum depression?
Karla Salem: You know, I’ve read information that says, they can experience it, but I don’t know why other than, you know, more on a psychological versus biological. A lot of males will tend to start questioning their ability to be a father. They’ll look at their own past and that will create some issues for them. Also, the area of fixing things in male brains tends to be more developed than in women just overall. I know there’s some women who do just a dandy job of always wanting to fix things, but male brains tend to be more onto that. And so, they want to fix the situation, especially if they see
there’s a lot of other kinds of things I think that enter into male emotions at becoming a dad. Sometimes I will do education with both, you know and then I’ll put the partner in charge, you’re in charge of watching this, this mood issue and you have got to do it nicely because if you make bad statements, I can’t guarantee your safety, but this is how we’ll use you to be sure to help us in monitoring. And that gives people, that gives the partners a function, it gives them a job, it gives them a way to help.
Courtney Collen (Host): Yes. I was going to ask you about the support that they can provide at home. You brought up earlier creating a sleep schedule. How can we help around the house if new mom is struggling?
Karla Salem: Well, and that is one proactive thing that families can do. And we used to offer a class that kind of talked to couples about this. So in South Dakota, where males do the outside work. Females do the inside work, which is, you know, manageable for many couples. Until you have a baby, then all of a sudden there’s way too much indoor work.
So, trying to divvy up chores and have things a little bit more equitable indoors, knowing that a mom’s time is going to be, especially if she breastfeeds is going to be very much overwhelming. And that can be very helpful before the baby’s even born. Because what can happen is both, both people, I mean just they’re humans. They just fight for sleep. They fight for, you know, who’s going to get to leave the house? Who gets to go to have a job, or now I have to work, can you get to stay home?
Courtney Collen (Host): Who gets to go to Target or make a coffee run?
Karla Salem: Yes, yes. So, getting things a little bit more evened up, at least for them, there’s no one formula that says this is the way it should be. But if there’s a meaningful conversation about it, the couple determines what’s fair for them and what’s better before the baby even comes, that’s a nice precedence to put into play.
Courtney Collen (Host): Sure. And what about a mother circle of friends or loved ones who can provide support? How can they step in and, and offer that support?
Karla Salem: So, I have had many, many women that had their first child and living at their home with their parents and they had mom’s help. Their second child was with a partner living somewhere else. And almost every one of them have told me, ‘Oh, it was so much easier when my mom was there’, because, you know, those are people that they trust mostly. And been through it and genetically are linked, you know, I mean, our brain chemistry is as genetic as our eye color. So, someone else in the family, if you’ve got anxiety, probably has anxiety so they know how to help you out.
So, family members, I find the best way is to just be there and to keep offering. I really try to encourage women to have planned schedules where people are coming in because if you have to call somebody when you’re at the end of your rope, it’s humiliating for women. It’s not fun because now ‘I’m not strong enough, I haven’t dealt well enough with it.’ And it’s better if they know, you know what, ‘I just need to get through till three o’clock’. So-And-So is coming. They’re going to help me with more labor intensive time of dinner and all of that. And it’s just really nice when help can come that way.
Courtney Collen (Host): So don’t say no to help.
Karla Salem: No, don’t say no. Just think of it as being incredibly generous. Absolutely. And sharing the experience. Yes.
Courtney Collen (Host): Yes. So you brought up visitors In those first weeks when you’re back home, maybe mom is nursing, you know, dad’s figuring out or partner’s figuring out the lay of the land here with mom at home with a new baby. How do we establish those boundaries? Family wants to come see baby and you’re just trying to catch up on sleep. How do you balance it all in those first weeks?
Karla Salem: Well, I had so many women tell me that’s the one thing they enjoyed about COVID because they couldn’t have any visitors. And they got to have a lot of time in the hospital with just their partner and them, and then once they got home, they also got to very nicely limit visitors. And so I always laugh because COVID for many people was very much, especially in the 2020 time, was very inconvenient and very much, you know a stressor. But for many women it was like, oh, so happy. I didn’t have to have anybody come over. I just got to get to know my baby by myself. Right.
And that’s possible to do whether there’s COVID threat or not. So it is the families, if they could just offer, let us know when it’s time for us to come, let us know when it’s best for you. That’s the absolute best invitation from a family who loves you that can happen because then you get to decide on your own without guilt or pressure. But if you can’t do that, then it really does become a couple’s effort to sit down and decide who, who in the family is helpful, who is toxic, so who the helpful people you start inviting in at your own leisure, you know, and people that will come and actually do something, not that you have to entertain while they’re there.
And then the other people you plan for a little bit later after the postpartum so that you have a little bit more endurance. But people coming in and just holding the baby so that women can, you know, clean up the mud room or put the dishes away or do something that makes them feel especially, busy-brained women tend to feel better if things are a little bit more neat and organized. And so having somebody to come in and play with your baby while you’re doing that becomes very helpful. Also, a lot of women will try to sleep during that time and some women are able to and some women aren’t, but I always tell women, don’t feel pressured to sleep during the day because if you’re lying there thinking about all the things that you would rather be doing then get up and go do them. Because sleep is better at night.
Courtney Collen (Host): One thing I’m learning so much is establishing those boundaries, but understanding that there is a kind way to say no, politely.
Karla Salem: Yes. You can have boundaries without anger. That is – and usually because it’s thought out and honestly, I have a lot of folks, a lot of women who have never been able to be confrontational or assertive their whole life, but now that they are, you know, representing their child, it’s a whole new skillset that’s coming out and they need a little bit of help with the confidence to do that.
Courtney Collen (Host): Go mama, go. What are some of the things that we can be doing during the end of pregnancy those last few weeks before baby arrives? Because we know that those emotions and those hormones, feelings of anxiety might be heightened once baby comes. What are some things that you would suggest we do as partners, as we prepare, making plans, things like that?
Karla Salem: People spend a lot of time organizing in that last month. They make sure there’s a place for the baby. They talk about their plan for feeding, whether they’re going to breastfeed, formula. They’ve done a lot of research on all kinds of things. So, it’s a lot of researching time as far as what they want to do after the baby comes. And a lot of people feel way more prepared.
They organize who’s going to be in the delivery room and that varies according to comfort level of the mom. I mean, there’s all sorts of configurations in the delivery room. Usually, they have somebody who is going to represent them and somebody who’s going to just constantly focus on them or they just have one person that does both.
And then usually there’s some discussion about who can visit and what that’s going to look like. Like many couples will tell their family, we want you to respect our first 24 hours in the hospital as just being us because we want to have time to, you know, to get to know our baby. There’ll be plenty of time for you to see us later, but the hospital is usually not the time because both men and women, partners and women are receiving so much information during that time. It’s just a bevy of videos and, you know, lactation and is so much to have visitors come in and exhausting is, is exhausting.
And so really considerate family will ask, but couples can make those kinds of decisions ahead of time and let people know what’s going on and then for when they get home. You can tell people, this is what our plan is for when we get home, we’re going to spend a couple of weeks, you know especially if the partner has time off too. A couple of weeks just getting used to routines and getting to know our baby, what the cries mean, how to get stuff done. And then a lot of people schedule out, you know, one family comes one week, the next family comes the next week so that there’s someone in the home, some kind of companionship even after the partner goes back to work, but it’s very methodical. I always admire people who are able to do all of that and then have cooperative family to do that with them.
Courtney Collen (Host): Karla looking ahead to the end of pregnancy, looking ahead to childbirth and the postpartum phase, are there any things that we can do to support our own mental health through each of these life-changing stages?
Karla Salem: I think women kind of go through a constant redefinition of themselves. You know, things that were important in one stage of life are no longer important. So, I think just a kind of a continual inventory of ‘how am I doing? Do I feel like, you know, I’m happy 80% of the time, if I’m content 80% of the time with 20% of the time being a little annoyed or a little bit emotional.’ And then from that inventory you go to, well, what’s causing, it’s always fun to find out what’s causing your joy and what’s causing your distress because the things that are causing joy, you can amplify and the things causing distress, you can start taking efforts and measures to try to address.
I always think the four basic things, sleep, water, eating, and exercise are always like the fundamental foundation of both health – mental health and physical health. So, it’s always good to take a look at that. How much am I sleeping? Our brain requires or would really enjoy five-and-a-half to six hours consecutive sleep so that it can clear out our memories. And it either puts them into long-term memory or deletes them. And since the human brain developed emails, they’re very similar. If you never clean out your emails, it’s going to be slowed, erratic, not predictable. And that’s what happens to our brain if we never get that amount of sleep.
Now you don’t have to get it every night, but at least try to catch up to what is recommended. And that’s always a good thing to kind of look at in that inventory. Am I getting enough sleep? Am I doing OK? If in your inventory you’re dissatisfied with something to the point where, you know what? I’ve been dissatisfied with this before and before and before now maybe it’s time to address it. I always think it’s a good thing if you have a primary care doctor to share that with them. Because they usually know all of the physiological kinds of things. They know about the mental things and they’re going to get you to someone who’s going to be able to help you. And maybe you’re not going to be ready right away but when you’re ready, at least you have the resources to do that.
Courtney Collen (Host): Well, this has been so valuable and I learned so much as I always do. Karla Salem, thank you so much for your time, for the conversation and all that you do to support so many women and mental health here at Sanford. Thank you.
Karla Salem: Well, thank you for the opportunity.
Read more about this topic
- Sanford Women’s Wellness Guide Program
- Learn more about postpartum care
- How to support someone struggling with their mental health
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