Understanding Your Moods When You're Expecting: Emotions, Mental Health, and Happiness -- Before, During, and AfterPregnancy - Softcover

LUCY J. PURYEAR, M.D., is a practicing psychiatrist specializing in women’s reproductive mental health. She has been director of the Baylor Psychiatry Clinic at the Baylor College of Medicine, and was expert witness for the defense in the trial of Andrea Yates. She lives in Houston, Texas.

Introduction

-Growing up as a young girl in Baltimore in the sixties and seventies, I watched in fascination as women fought for equal rights. But I didn’t fully understand why they had to fight for them. As the firstborn child of a man who wanted a son, I was treated like one. My father claims I knew the names of all the positions on a football team by the time I was two. I was allowed to do anything the boys did. My father taught me how to throw an almost perfect spiral and how to shoot a rifle and hunt dove in the Rio Grande Valley. I read the books he’d read as a boy and couldn’t imagine that girls could be treated differently than boys.
From watching television, I knew about Gloria Steinem, Billie Jean King, and the campaign for the Equal Rights Amendment. I wasn’t old enough to have a bra to burn, but I would have burned it if I had been. I was determined not to let the fact that I had been born female stop me, and my parents confirmed that I could do anything I wanted to do. A desire was born in me to accomplish something that made a difference.
As a college student, I became involved in women’s health issues and thought about becoming a midwife or an obstetrician. But as I watched the doctors working in the clinic where I volunteered, I became disillusioned with the way some of them dealt with their female patients. These doctors often treated the women’s physical symptoms but ignored or trivialized their emotional complaints. When at age twenty-five I complained to my own gynecologist about having premenstrual mood swings, he literally patted me on the head and with a patronizing smile said, Lots of women have that, honey. Don’t worry about it.” I was embarrassed and furious at the same time. I felt like an overly emotional little girl and angry that my complaint hadn’t been taken seriously. At that moment, I decided that I would go to medical school and become a different kind of doctor. I would be a physician who listened and treated women with respect. I imagined myself as an obstetrician who sat by women’s sides as they delivered their babies, listened to their stories, and educated them about their bodies.
I began medical school and was soon confronted with the limitations of the health care system. I realized how difficult it would be to practice obstetrics in the way I’d fantasized. There doesn’t seem to be enough time in the day for doctors to see as many patients as necessary to make a living and also to have a personal life outside of work. The legal climate forces physicians to practice defensive medicine, performing procedures that may not be necessary. New technology often causes doctors to treat lab results or monitors instead of patients.
The few female obstetric residents I knew were subtly conditioned to act like their male counterparts tough and efficient to be respected. There was no handholding or staying with a woman while she labored. It was often the nurses who delivered the baby. The doctor’s arrival was carefully timed to appear when the baby was almost born and there was not much left to do but cut an episiotomy and sew it up. It was not that the doctors were lazy or didn’t want to be there; it was just that they had too many women to care for, had too much paperwork, and were too sleep deprived.
In medical school, as I contemplated what the next step for me would be, I was torn. Delivering babies was fun. It is amazing to help a woman give birth through her struggles and her pain. I could watch the television show MaternityWard for hours on end and never tire of seeing the mixture of relief and awe on the mother’s face when her infant was finally delivered.
Being privileged to help guide babies into the world is an incredible feeling. But I had a young daughter and wanted more children. An ob-gyn residency is very difficult, and I knew life wouldn’t get much better once I was finished. Many obstetricians stop delivering babies after several years due to malpractice insurance costs and the great demands the work makes on one’s life. My concerns about whether I could be the kind of doctor that I wanted to be only grew.
Gradually, I realized that psychiatry was a field that could allow me to practice medicine in such a way that I could be fully attentive to the whole woman. As a resident in psychiatry, I couldn’t wait to get up in the morning and go to the hospital. I looked forward to reading everything I could about psychiatric illness and its treatment. The patients were fascinating. Each day would bring a new story, a new tale of human strength in the face of suffering. I learned that all of us have pain in our lives and all of us have families that are less than perfect. As a general physician, I could treat pneumonia or diabetes and save someone’s life. Yet as a pppppsychiatrist, I could help people out of chaos in a way that allowed them and their families to live in the world with joy and hope.
During my psychiatry residency, I was asked to help teach ob-gyn residents about diagnosing and treating psychiatric illness. I began to work in the high-risk obstetrics clinic at Houston’s Ben Taub General Hospital. There I saw pregnant women who had histories of psychiatric illness or had developed psychiatric symptoms during their pregnancies. It was my job to decide whether medication was necessary and if so which medication would be safest to use.
After several months as attending psychiatric resident in the high- risk clinic, the ob-gyn residents began to seek me out to ask questions about their patients. They became more interested in evaluating and treating their patients for emotional symptoms. Women from outlying community clinics began to be referred to Ben Taub for the specialized treatment we were offering. I was increasingly asked to give lectures to other health care providers about psychiatric illness during pregnancy. My future now seemed clear to me.
I realized that there was a huge hole in the mental health care available to pregnant women. Many women wouldn’t ask for help out of fear and shame. Many were told they couldn’t get treatment while they were pregnant. They were told that because they had depression, anxiety, or bipolar disorder, they shouldn’t have children. They also were told that they were at risk of losing custody of their children if they remained mentally ill. And when a woman with a psychiatric diagnosis became pregnant, I was not infrequently asked to decide whether the state should take the infant away after delivery.
This presented a terrible challenge. I was being asked to decide whether a mother was going to be too sick to care for her baby and to evaluate whether the baby would be better off in what I knew was a woefully inadequate foster care system. Unless I could prove otherwise, it was assumed that a woman who had a psychiatric illness could not be a good mother. The women themselves faced a dilemma: they were being told on the one hand that psychiatric medication was not an option during pregnancy, but on the other hand that if they remained psychiatrically ill, they might not be able to care for their children and could even lose their right to parent.
This experience intensified my desire to advocate for women with psychiatric illness. People with mental illness make many of us uncomfortable and frightened. Historically, it was easier to lock mentally ill people up and ignore them. But all of us at some point in our lives will either have an emotional illness or know someone who does. One out of four women will develop a depressive illness at some time in her life. That could be you or me, your sister or your mother. And all of us have moments when we struggle with sadness or frustration or feel overwhelmed.
Although we may not be diagnosed with an identifiable psychiatric disorder, we may often find life tumultuous and stressful.
After four years of residency, I joined the faculty at Baylor College of Medicine in Houston. I started a women’s psychiatric clinic and began to teach psychiatry residents and medical students how to care for women of reproductive age. I knew that I had found my place taking care of women who were struggling with mood symptoms during reproductive events in their lives. For me this is the perfect combination of obstetrics, gynecology, and psychiatry.
Some people call this specialty reproductive psychiatry. At the time I started my professional life, very few psychiatrists knew about the interplay between women’s hormonal fluctuations and their moods and mental health. I became an expert in treating women with severe premenstrual syndrome (PMS), pregnancy and psychiatric illness, postpartum mood disorders, and depression during perimenopause.
Today there are more women asking for this specialized type of care than I could possibly see. Some of my patients come from very far away because there is no one in their area with the specialized knowledge to care for them during pregnancy or the postpartum period. Many women slip through the cracks. Many obstetricians and gynecologists are not trained to recognize the signs and symptoms of psychiatric disorders. They typically see a woman six weeks after she delivers her baby and then not again for a year.
Future doctors need to learn more about issues specific to women, not just regarding psychiatric symptoms but also other diseases as well. Heart disease is a good example. For years people believed that women did not have heart attacks. Now we know that the symptoms women experience during a heart attack are often very different from those that men complain of. Women die from heart attacks because of the failure of medical science to pay attention to their specific needs.
Unfortunately, women who have emotional problems during pregnancy or after the baby is born nearly always feel shame and guilt. This compounds the problem of getting the right help. They believe that if they are experiencing anything besides great joy, all the time, they are bad mothers. Women often don’t talk with helpful seriousness about the baby blues or about how having a baby was harder than they expected. These aren’t common topics during prenatal classes or at baby showers. Instead, we all talk about how excited we are and how cute those tiny clothes are. If a new mother has difficulty adjusting, she will more likely suffer in silence than seek help.
On the first day of my psychiatry class with the first-year medical students at Baylor College of Medicine, I ask, How many here have asthma?” Five to ten students usually raise their hands. How many have GI [gastrointestinal] reflux?” Another three to five. When I ask, How many have mental illness?” stillness falls over the 168 students present. A few people may giggle. I rephrase my inquiry. Okay, how many people in this room have a family member or know someone with mental illness?” Just about everyone’s hand goes up. I never really expect anyone, in a room full of their peers, to fess up to having mental illness themselves, but the exercise dramatically makes my point. It is not socially acceptable to have a psychiatric disorder. It is particularly difficult to be a new mother who is feeling less than happy about having had a baby.
It is time to acknowledge how disabling psychiatric illness during pregnancy and the postpartum period can be for both women and their families and how proper recognition and treatment can change their lives for generations. It is also time to realize that being pregnant and having a baby is hard work both physically and psychologically. It is not always fun being a mother. Most mothers would never choose to give up the experience, but they all need support and understanding. Knowing what may lie ahead can bring women one step closer to knowing when they may need help. Early recognition and treatment of symptoms may prevent more serious problems from arising.
Many books discuss the joys and pitfalls of pregnancy. These books offer information about the physical symptoms a pregnant woman may experience and common remedies to alleviate heartburn, sleepless nights, and lower back pain. Methods of delivery are reviewed, and women are encouraged to choose the type of birth that fits their physical and emotional needs.
But very few of these books talk about women’s emotional health before, during, and after pregnancy. Some give helpful information about postpartum depression and anxiety, but most women will turn to such books only after they’ve experienced distressing symptoms.
Understanding Your Moods When You’re Expecting is an indepth look at the spectrum of feelings that women may experience, from the normal to symptoms that are more problematic, for which professional help may be required. It is an attempt to focus on psychological health and to acknowledge that the emotional issues that arise during and after pregnancy are as important as the physical ones. Having a baby isn’t just a physical experience; it’s a profound emotional experience as well. This book provides essential information for women who are pregnant or wish to become pregnant and for their families.
The book explains options available to new mothers who are struggling with thoughts and feelings they did not expect. When are the feelings serious and medical help necessary? What medications can you take while you are pregnant and breastfeeding? When should you consider medication, and when are other treatments a better choice? Can psychotherapy help?
The book also contains information that will help keep women and their families whole and healthy during pregnancy, childbirth, and the postpartum period. It gives voice to the doubts and anxieties that every mother feels even while she is experiencing the joy of bringing a new life into the world. Talking about the emotional upheavals of pregnancy and childbirth can prevent women from suffering in silence and reduce the risk that women who need help may not get it.
Understanding Your Moods When You’re Expecting discusses the normal emotional and psychological responses to pregnancy and childbirth. Most women do not suffer from a diagnosable psychiatric illness during or after pregnancy. Yet all women have good days and bad days. They may be confused about what they are feeling and not know whether their feelings are common and short-lived or more serious and longer-term.
Many of the women who come to see me say, If only I’d known what to expect. Why didn’t anyone tell me how hard it could be?” If women and their families can be empowered to get the help they need, potential suffering and tragedy can be avoided. Many women experience mood changes in response to normal hormonal fluctuations. Until recently, little attention was paid to what causes those symptoms and how to respond to them effectively. It is important for women and their families, and for the physicians who treat women, to realize that the reproductive years are a time when women’s mental health is linked to what is happening to them hormonally. In addition, women with postpartum mood disorders are at increased risk for a recurrence with subsequent pregnancies and around the time of menopause.
Being pregnant and giving birth is a time of great biological and physiological change. A woman is not only experiencing physical changes that can be overwhelming, but she is also trying to adapt to emotional and psychological changes as well. A mother is not created when her baby is born, but when she can wrap her mind around what it means to her to be a mother.

Copyright © 2007 by Lucy Puryear Reprinted by permission of Houghton Mifflin Company