Tanya:

Hey everyone. Welcome to episode two of season three of the mother wit podcast. My guest today is Rebecca Feldman. She is a Certified Nurse Midwife and a Psychiatric Nurse Practitioner. She's the founder and director of Brooklyn parent support. She specializes in medication management for pregnancy and lactation, and she is super passionate about group support. So we're definitely gonna talk about that in the episode. I'm gonna leave it at that. I have COVID as I'm recording this intro. And so I don't feel like talking anymore and Rebecca does a really good job introducing herself here in a moment. So without further ado, enjoy the episode. Oh, and a gentle reminder that nothing we discuss on this show should ever be considered medical advice. Please speak to your local provider about anything that comes up in this show that resonates with you and your needs and your healthcare. Well, hi Rebecca, thank you so much for joining me today.

Rebecca:

Thank you for having me. I'm really excited.

Tanya:

I'm really excited to have you too, because your career I've had the pleasure of watching it shift and change and grow, and it has been super fascinating to me and even more so as I started doing the work that I'm doing, because everybody's heard me say this a million times, I had no idea the depths that I would go in terms of working with people in relation to their mental health until I was in it. And I love it, but it's also the case that I am only a midwife. I don't have these extra tools that you have added to your tool bag. And so I think it is a little late actually for me to have you on the show. I should have had you on two seasons ago, but here I am happy to have you now. And sometimes on the show, I think we've dived in really deep on just the real issues that people are out there having, but we haven't actually provided a really solid backbone and some definitions and given people some solid tools. And so even though it's a little late, it's never too late and I would love to have you give us all a bit of a primer. How do you feel about that?

Rebecca:

Sounds good.

Tanya:

Great. Well, before we get started, I think you should tell everybody who you are share whatever personal and professional details you feel comfortable sharing.

Rebecca:

Okay, great. I'm Rebecca Feldman and I am a nurse midwife and psychiatric nurse practitioner. And most of my career was in labor and delivery as a labor and delivery nurse and midwife. And I just, through that time, I loved working with mental health and prevention of more serious mental health conditions was always something I was really interested in. And so I, so I worked as a midwife for nine years and I got more and more interested in the mental health part. And I didn't wanna go back to school because I actually was really happy with my job as a hospital midwife. But I became increasingly frustrated with the lack of services that I could find for the people that I was working with. And so in particularly around medication and pregnancy and lactation, I just wasn't finding that there's not enough people to do the work.

Rebecca:

And so a lot of times my clients were seeing people who weren't specialized and they were getting very often told to come off medication and then they would feel worse and they would have much more challenging pregnancy and afterward. So I went back to school and became a psychiatric nurse practitioner. And I really wanted to work in psychotherapy as well, which we did receive training in psychotherapy, but I went to a three year psychotherapy program as well. And I'm very passionate about group work. So I use my psychotherapy background most often with group work. So I have a practice now in Brooklyn that's called Brooklyn Parent Support and we are a group of five nurse practitioners. Now two of us are midwives as well as nurse practitioners and we have one social worker working with us and we have a bunch of groups. So we'll talk more about group support for pregnancy and postpartum. But that's just a little bit about, oh, and I'm a mom of two and stepmom of one and they're all boys. And it's really interesting living with all boys and working with mostly women, but not only women, but there are two of them going into high school. And then my youngest is just finished elementary school.

Tanya:

Wow. You got a lot going on

Rebecca:

Uhhuh.

Tanya:

That's a, that's a busy life. Yeah, it is. It's true. I met you at Brookdale?

Rebecca:

Yeah. Yeah. And I liked you immediately and it was so great to work with you. Yeah. And I mean, working there, cuz I've worked in two hospitals in Brooklyn that were really underserved hospitals and those, they really stoked my passion for working in mental health. Both of those hospitals at, at Brookdale, we saw a lot of severe persistent mental illness in pregnancy. And the good news is that they could be great outcomes for people who live with those illnesses. But unfortunately at that time we really weren't seeing that.

Tanya:

Yeah, yeah. That, that was a long time ago too. I mean a lot has changed and evolved yes. In this timeframe.

Rebecca:

Yeah. We know so much more now that was 2008, I think when we were there.

Tanya:

Yeah. Something like that. Yeah.

Rebecca:

Yeah. We know more now and yeah. Things are changing slowly, but they are.

Tanya:

Yeah. And just for our listener's sake, I don't have the experience from this place. We're talking about Brookdale that Rebecca has because I was actually only there for six weeks. It's a funny, not funny haha, but funny story that they were doing a massive layoff at this hospital and they laid off 300 people in one day and I was one of them because basically what they did their strategy was to lay off the newest people in every department. So I was laid off six weeks after starting there. So I have very, very brief memories of Brookdale. So as Rebecca's recalling that, I wanted to let everybody know that I don't have that context. She has about the severe mental illness from this workplace.

Rebecca:

Wow. I didn't realize it was only six weeks.

Tanya:

It was only six weeks. It's true. It's, it's a wild story. I was a little traumatized by that moment of my life. You don't think you're gonna start a new job and have that happen. So any who, okay. Now that we've figured out our history together I am gonna ask Rebecca to dive in. I wanna give everyone a chance to really take in Rebecca's perspective on the three most common things. I think everyone should know. We could go on forever and go into the things that are less common, but I don't think that's a good use of our time in this episode. So first we're gonna talk about baby blues and then we can kind of segue into postpartum depression, because I think there's a lot of confusion for people there and we can kind of unpack, people's lived experiences of, you know, where the confusion lies in those two things.

Tanya:

And then we can take postpartum anxiety kind of separate from that. So I'll turn it over to you. Tell us what you think we need to know. And just to frame this, I really want this to be helpful for both consumers of healthcare and healthcare providers, because I think we have healthcare providers listening, who come from all sorts of different backgrounds, all types of birth workers and even people who don't do overt birth work, but sometimes interface with just women in general who have had babies. And so I think everybody needs this information.

Rebecca:

Okay, great. But the more that I do this work, the more like the pregnancy and postpartum piece kind of blurs together for mental health. Because I mean my favorite scenario is when people come to me because I do mostly psychiatric evaluation and medication management and I also do psychotherapy, but that's really the bread and butter. I was gonna say the meat and butter of what I do, the medication consultation and management for pregnancy and postpartum. And then of course the group support. But when people come even prior to pregnancy, especially people who have had, you know, a history of depression, anxiety, bipolar, or whatever it is. And then we can start making a plan even prior to pregnancy because one of the difficult things is when people start treatment in pregnancy, very often they have stopped medication to be pregnant and then they don't feel well.

Rebecca:

This is a common, reason that people come to see me. And then they've started the pregnancy not doing as well as they could. So optimizing the mental health prior to pregnancy is really ideal and a challenge. But that is the most preventative is when we can really optimize mental health through pregnancy. And then we don't see as many of the postpartum mood disorders as we're gonna talk about now. But starting with the baby blues that is a universal scenario where most of us after having a baby, it's usually around 80%, but it's probably more like everybody has the emotional shift following the birth of the baby. And it can look many different ways, but it often corresponds with like around the time that the milk comes in, because there is such a profound shift in hormones at that time.

Rebecca:

And and also it is a time where the wall of sleep deprivation and we'll talk about sleep throughout this podcast, but the wall of sleep deprivation kind of hits people hard and corresponding with the changes in progesterone and just getting used to being responsible for a human being 24 7 sometimes for the first time. And then obviously like all the physical changes as well. So most people feel intense feelings, maybe crying more easily or crying more often. But when we consider it baby blues, it's the overall feeling is a feeling of contentment or even joy like interest in the baby, liking the baby, not always in love with the baby, cuz that's something that I talk about a lot is that like we don't always fall in love the moment the baby comes and it's nice if it happens, but not a requirement for bonding because sometimes, you know, they we've gone through a lot. They look pretty weird at first and it just takes time.

Tanya:

You mean? You mean Rebecca? Not all babies are perfectly adorable and cute. The second they come out, you know, some babies look like little old men and some babies look like little aliens and they eventually turn into adorable babies, but it doesn't happen right away. And also we might fall in love with those babies. And also we might not like the really cute ones we might not fall in love with right away. I think that's one of the most interesting things I face is the shame someone feels if they aren't talked to in advance about the fact that they may not fall in love instantly. And it's amazing what, just talking to someone in advance of the birth about that does to prevent this horrible feeling, right?

Rebecca:

Yes, absolutely. I mean my personal experience with that was my second, my first one and they know this story, so it's okay if they listen to this podcast, my first son was very, very cute immediately. Like just so cute. And I had such a long labor, but when I looked at him, I've thought it's all worth it. I just love, love you so much. My second one, it was just, the labor was hard in a different way and it was just everything. It was very challenging and he just didn't look very cute. And he looked like a little wrinkly, kinda skinny wise creature. And I, I did not fall in love immediately, which I think also is sometimes more common after the first baby, but not always, but because you've already gone through that transition of like, I'm a mom, if that's what you wanted like it is different the second time, you know, more about what is about to happen, how much life changes.

Tanya:

Yeah. And that can almost be more scary, right? Because you, if you don't know what's coming your way, you have nothing to be afraid of. And if you know the challenges that are coming, you can sort of get ahead of yourself almost right. And then sometimes second babies can be easier. And sometimes that's because our temperament is different cause we trust ourselves and there's just all these different variations that can unfold.

Rebecca:

Yeah, it's true. My second one was was easier. Now he uses they them pronouns, but at that time when he was born, we called them. He, but yeah, he was a super easy baby. But I was thinking like, how do you do this with two? Like even in I, there was this Cesaean birth, even in the operating room, I was thinking like, wow, I've gotta go home and recover with a toddler too. But with the, going back to the baby blues, the feeling like you might have all of some, you know, similar feelings or different feelings than what I was having. But overall there's this contentment or even a hopeful feeling. And people can, if it's the baby blues typically like sleep is possible. Like if you're very tired, you can fall asleep. Appetite is there.

Rebecca:

And, but the crying can be for sure, like more easy more easy to cry and just like an overwhelmed feeling and it will pass. And that if that those are all the case, that's the case. The sleeping is happening, you know, when you can appetite, is there no thoughts of, you know, wanting to die or escape that typically passes as the hormones kind of start to settle and hopefully some sleep and care from other supporting family members. But we, I mean, I think I remember learn and I do remember learning that, you know, within the first two weeks, it's just the baby blues, but that's really not true because

Tanya:

I wanted to ask you about that. You have found this to be factually untrue.

Rebecca:

Yeah. Because I mean, some people will feel like profound anxiety or trauma response or very depressed even very quickly after the baby's born. So I wouldn't say okay. You're, you know, so anxious that you can't sleep, but it's only been a week, you know, because you want to, if somebody is really struggling and doesn't have that kind of overall overarching feeling of contentment or joy especially, you know, sometimes people will feel even suicidal quickly soon after birth. And for some people that's related to hormonal changes

Tanya:

Mm-Hmm, but would you still call that baby blues?

Rebecca:

No.

Tanya:

No. You would call that postpartum psychosis

Rebecca:

No. Or not. Well, so if somebody is feeling very depressed following the birth of the baby and it's still within two weeks, but they have feelings of hopelessness or wanting to die not feeling connected with the baby. And then usually like the real insomnia and unable to eat. Then I would call that postpartum depression, even if it's within the week, especially if there's suicidal thoughts, but postpartum psychosis is very different though. Does happen usually within the first two weeks, but can happen outside of that time. But postpartum psychosis usually is related, not always, but about half the time or a little bit more related to untreated bipolar disorder, which is not uncommon. It sometimes is the very first episode of a bipolar manic episode can sometimes happen in the postpartum time.

Rebecca:

And that's not uncommon because the age that bipolar disorder usually begins is like mid, early twenties to mid twenties. So a nor a very common time for someone to be having their first baby. And and I know we said we were gonna talk about baby blues, anxiety, and depression, but I'm glad we got into this too. Because I think it's really important that we talk about postpartum psychosis more because it is rare, but we talk about other rare things more than we talk about postpartum psychosis, and it can happen to anyone it's about one in 1000 births which is is rare. But as you know, we've been midwives for a long time. So we've certainly worked with a lot, you know, thousands of people. And I work with postpartum psychosis pretty frequently now. Usually people come to me after having had a psychotic episode and been in the hospital and then for continued care, that's, that's not an uncommon referral for me. But usually, so like I was saying that it could be the very first time someone has a postpartum manic episode. But if someone knows that they have bipolar disorder, it's just so important to prevent postpartum psychosis, which we actually can do by continuing treatment with medication through pregnancy.

Tanya:

Was gonna say, I'm actually really glad that we kind of diverged and did these two things, this one thing that's kind of simple that everybody has up against this one thing that's really rare that hardly anyone has, because we don't talk about it enough. You're absolutely right. And they overlap in that timeframe, which is what I was trying to get at. Initially, once you said suicidal, I kind of thought that's where you were going with it, but I'm glad that you then unpacked it even more than that. So that we didn't drill down to an oversimplification, which was baby blues, postpartum psychosis. Those are the only things that can happen at the beginning. I too have been taught probably too many times that, oh, well, postpartum depression usually starts later. Right. And although that may be somewhat a true statement, we can't buy in so much that we don't see postpartum depression happening when it does happen sooner.

Rebecca:

Yeah, yeah, absolutely.

Tanya:

Which I think is what you're saying.

Rebecca:

Yes. Yeah. And the anxiety and depression for most people are very intertwined. I mean usually when I'm working with somebody, one is predominant. One is the dominant feeling, but usually there's both and more common. So postpartum depression and anxiety like the numbers we don't know for sure. And that's why now the umbrella term is usually perinatal mood and anxiety disorders that includes bipolar disorder and PTSD and OCD. And all of these things are usually can be mixed in together, but anxiety, I work with much more than depression.

Tanya:

I would agree that I see anxiety much more than depression. Also. I see depressive features just as you've said, but at least the people who come to me, which is why, I can't know for sure whether this is a trend of who seeks out my support, or this is the way it is across the board. I think I see anxiety much more and yet people don't think that that's the case.

Rebecca:

Right. Right. Yeah. And I mean, it can certainly turn into depression cuz when you have the persistent, anxious feelings and trouble with sleep and trouble with eating and trouble connecting with the baby because of so much worry. Then it does lead to feeling depressed for most people, cuz it's so hard to have that type of anxiety, but that, and postpartum anxiety, which it is more common than postpartum depression. But we don't have like exact numbers, but we usually say, you know, one to five to one in seven people have perinatal mood disorders during pregnancy or after pregnancy through the first year. And then during the pandemic it's been much higher. I mean, especially in the early times, I mean there was very few people who weren't experiencing depression or anxiety after having a baby. But with the anxiety postpartum, usually it starts when people come to me who are feeling profoundly anxious, they usually started to feel that in labor or in pregnancy or immediately after the baby is here.

Rebecca:

And what we do in the hospital with sleep is makes it all worse because you, if one of the preventions for anxiety and depression is getting sleep and the hospital makes, I mean, it's, it's very, very hard to sleep in the hospital. So if, especially if someone had a longer labor or an induction or a surgical birth and then the sleep is broken up, not just by the baby, but also by you know, everyone coming in and out and having a roommate and all of that the anxiety starts to build. And one of the other risk factors for postpartum anxiety is NICU or separation from the baby. It can be, that's a very common start to feeling, you know, pretty anxious. So, but, but also anxiety during pregnancy, we should be paying more attention to because it has effects.

Rebecca:

And people who treat their anxiety during pregnancy often have much less anxiety postpartum. And what I mean with treatment, it could be medication, it could be therapy, it can be both, it can be groups. So there's all different approaches and it depends on the person, you know, which combination of treatments is going to work. But one of the things with pregnancy anxiety and postpartum anxiety is this need to to check on things, which of course is like a very normal parental maternal instinct is to check on the baby. But I mean we, as midwives, we know like we've worked with people who are just constantly checking on what's happening with the pregnancy and, and then the way that we do prenatal care of course exacerbates that with like the checking of everything so one of the things I do working with people during pregnancy who have a history of anxiety is just working to minimize the checking because and the kick kick counts too, are just like a great place people to put their anxiety. So trying to minimize that if it's, you know, if it's possible because when the baby's here, then the checking can be, you know, even worse and very hard just to sleep. So that's one of the things that we work on your pregnancy.

Tanya:

Absolutely. do you have any particular thoughts on how both for both providers and consumers, again, how we can do a better job differentiating between sort of a normal, healthy level of anxiety that everyone's gonna pass through and when maybe it's a little excessive?

Rebecca:

Yeah. That's I mean it is tricky. But there is, I mean there is anxiety serves a purpose and we all have anxiety. There's no person that's never experienced anxiety. And sometimes the anxiety is telling us that there is some type of a threat, but if it's like an all consuming kind of feeling that there's a general feeling of worry and concern and it's hard to enjoy, it's hard to have fun. I mean, that's usually what I ask people to kind of gauge some of this is like, what do you do for fun? And so many people laugh and are like nothing. What do you mean? Like, what is fun but it's important. I mean, for me like the sleep and the appetite are just like so helpful for me to understand like how pervasive the worry is.

Rebecca:

So, I mean, most people have trouble sleeping during pregnancy at least at some point, but I really find out about the quality of the sleep. Like, can you, are you waking up with like a racing heart or waking up with specific worries or fears or are you just waking up cause you have to pee or cause the baby is moving that kind of thing. I mean, and then also like trauma is so intertwined with all of this too. So finding out like, is the fear because is it related to some type of trauma? Is it like a flashback kind of feeling or, you know, from another pregnancy or from other medical experiences and then there's specific types of therapy that can be really helpful for that, but lack of appetite that's really important because sometimes people are like, well, I mean I can, especially cuz I know we'll, we'll get into medication.

Rebecca:

Some people will tell me like, well I can just make it through the pregnancy with the anxiety like, I'll make it through and then I'll start my medication as soon as the baby's here, but it's not a benign thing to be anxious. It could be like if you're able to have fun and you're able to eat three meals a day and you can sort of, you know, sleep okay at night that that would be a manageable level of anxiety. But if there's no appetite, you know, that means the stress hormones are really circulating in a way that isn't great for pregnancy.

Tanya:

Yeah. And that there was a therapist that I worked with who had a nice, concise way of saying this and I don't remember exactly what it was. Maybe you do. There's oh, I know what it was. There's no such thing as no exposure. Just so simple. There's either exposure to stress, anxiety, the hormones that come with it or there's exposure to medications but people put on blinders and they only think about the exposure to the medication. At least that's how it seems. And that's for both providers who are telling people to get off their meds and for clients that are afraid to be on meds during pregnancy or during lactation.

Rebecca:

Yeah, absolutely. Yeah. I mean, it seemed like there's a lot of discussion in perinatal psychiatry about like we're looking, we've been looking at the wrong things for decades because the medications you know, SSRIs are some of the most studied medications in pregnancy. And the safety profile is good. But we have so much information about the risk of depression and anxiety during pregnancy and in those early postpartum months that we, yeah, that's exactly right. We have to really take into account the risk of the mental health issues versus medication. And and it can be a really difficult switch in people's minds because most people do think, you know, I'll get through the pregnancy without my medication. And we have to really reframe that as, you know, having your and also like we don't want to, something I talk about a lot is if you do take medication and we'll get into like, what specific medications are we talking about? But a lot of people will say, let me take it down to the absolute lowest. And we want people to be on the lowest effective dose so that they feel well and can sleep and eat and have fun and feel, you know, somewhat excited about the baby that's coming, if that's possible. And if you're on too low of a dose of your medication, then you're exposing the pregnancy to both the illness as well as the medication. And that's probably what your other speaker was talking about too.

Tanya:

Yes. And another thought though, is that in a huge misconception, I think people fight to stay on the lowest dose because they're afraid of just more exposure of course, but what they aren't thinking about is that the dose you're on doesn't mean that you are more sick than someone else. Like we are all individuals and we all respond to different dosages, not to mention pregnancy is just wild on the metabolism. And so we just can't really know. And so I talk to everybody about not buying into this idea that if you need a dosage increase, that you should be fighting and resisting. No, I think I can stay on this dose and I see people trying to do that. So that's another mission I end up on.

Rebecca:

Oh, that's great. Yeah. I mean it is, cuz I do these genetic tests for psychiatric medications that we can we have access to now and we're still learning about it and not totally sure how important they are, but, but I do learn from using them. And one of the things I've learned is that we just metabolize medications completely different depending on how our receptors are are made and that's very individual. And so yeah, and it has, doesn't have to do with weight. It doesn't have to do with size and it doesn't have to do with severity though with anxiety disorders and obsessive compulsive disorder, people do usually do better and feel better on the higher end of the doses, but that's kind of like a general rule. But I also, I, you know, I love to tell people that I've seen a lot of placenta and they're very big and I mean, they, you know, they usually weigh two to three pounds and they're nice thick, meaty organ.

Rebecca:

And that's, what's filtering this medication through and they're very, very good filter and the research on using medications in pregnancy for, in all classes of medications, it's not dose dependent. I mean there's certain medications that dosing is really particular in pregnancy like lithium or Lamotrigine. But for the SSRIs, 75 milligrams of Zoloft could be much less effective than a hundred. And so that could make your pregnancy much happier and healthier, but really no change at all to what the exposure is to the fetus. So, and I usually tell people that more often than not, no, that's not, I usually have to go up on medications in pregnancy, not down. And so, I mean, that's especially if I'm seeing people even before pregnancy, that's something just to think about because of fluid volume and blood volume and all of that, and even just the stress of pregnancy itself.

Tanya:

So it sounds like in an ideal world, right. I, I also spend in addition to harping on issues about postpartum care, I obviously also harp on issues and preconception care. And it seems to me that one of our biggest shortcomings here is preconception care for people with an underlying mental illness prior to pregnancy. If we were working with them carefully and closely, as they prepare for pregnancy, we might be able to prevent all of this coming on, coming off, starting, stopping, changing meds and just keep everybody smooth throughout, now that's different than someone who wasn't on any medication prior to pregnancy. Now, regardless of whether they maybe had an, had a disorder that wasn't being treated or it pops up new in pregnancy, let's say. I kind of wanna see if you can give us a little bit of a framework for approaching the use of medications in someone who wasn't previously on anything, somebody who never took anything before, but we start to see the onset of mood disorders in pregnancy. And then maybe how does that change when it is somebody who already is on a medication?

Rebecca:

Your questions are so good, Tanya. So yeah, I mean I would, the vast majority of people that I work with did have some type of mental health history previous to working with me. But I mean, not always the case and sometimes it's related to fertility. I work with a lot of people who are going through IVF and it's obviously stressful, but there's also like the whole hormonal, the intensity of adding the hormones and then just, you know, getting through each month. So I would say like that population more often does not have preexisting mental health conditions just of my, my group of patients. But they often feel anxious from the fertility challenges in the hormones. But then another scenario that's not uncommon is first trimester anxiety. So sometimes I'll see people like usually a desired pregnancy, but not always.

Rebecca:

But there's just this intense anxiety that can happen in the first trimester. And I think that, you know, typically if it's really intense, I do use medication. But depending on the situation, I mean, if someone has not had therapy before starting with psychotherapy and just learning some grounding techniques and mindfulness can make such a huge difference. So it just depends on what exactly is happening. I mean sometimes it's, it's really just the sleep we have to work on sleep. And yeah, once somebody can sleep, the anxiety starts to improve.

Tanya:

I love talking to somebody who understands the role of sleep as much as I now do. It's, it is the dominant conversation I'm having with people for close to the whole first month postpartum generally. Right. Because I feel like I can't even sort out in most cases, sometimes it's blaringly obvious, right. But, and other times what we're doing is saying, I can't tell how much of this is overt anxiety, unless we get you sleeping. So it becomes this dance between how do I get your team to give you just the right amount of help without undermining you? What, how do we position breastfeeding or whatever it is that you want out of that, up against the fact that the truth is breastfeeding and preserving someone's mental health and sleep don't often go hand in hand. And so there's lots of compromises to be made there.

Tanya:

So that's an ongoing daily conversation like this, this doesn't work in our current healthcare system, giving someone this degree of support to smooth them out. But I have smoothed so many people out just by harping on sleep. Now once or twice. I do think I have contributed to somebody's anxiety by harping on sleep, however, and that has been interesting. Oh, awesome. And I don't know how I could have done that differently. And both of those people that I can think of are still very pleased with having the support that I provided and what we did was we ended up going through the series of medications that helped with sleep. And ultimately we still ended up landing on anxiety and treating the anxiety and then it went away. But sometimes I think I may have contributed to that by harping on the sleep issue. Have you ever seen that before? Like have you ever felt like maybe a provider goes too far and makes somebody worry about sleep more than they should?

Rebecca:

Well, I have lot, a lot of people who are anxious about sleep and then also anxious about anxiety medication, you know, it's but usually like when the anxiety, I mean, I think group is so helpful for that. And our group support. We have mixed pregnancy and postpartum groups. So there's interesting other stages. And I even have a therapy group I've been doing now for about two years and some of the people are having their second baby and have stayed in the group that whole time, but it's really helpful to see people who are on, you know, all the different sides of this. But yeah, I have seen that. I mean, because especially if it it's related to like checking obsessions about it can be very disturbing and upsetting to try to focus on your sleep when you feel compelled to check on the baby every, you know, five to 10 minutes but I think sleep is, yeah, it's the key to mental health.

Rebecca:

Within kind of what I find a lot is that what I was taught about breastfeeding as a midwife is now is, was not actually right. I mean, I, I usually tell my patients that in my, I mean, they're coming to me for mental health, so we're gonna prioritize mental health above breastfeeding. And most people that are in agreement with that, you know, because that's why they're seeing me. And what I usually say is that in order to prevent postpartum depression or anxiety, but even preventing postpartum psychosis is dependent on sleep. Cuz the medications are a big piece, but mania, which is what postpartum psychosis often is, is triggered by sleep deprivation. So I usually tell people like for whatever reason, they're seeing me that less than five hours of solid sleep in the first few weeks postpartum put does put you at risk, which,

Tanya:

And when you say five hours, do you mean consecutive or spread out over 24 hours? How are you using this right now?

Rebecca:

Solid five hours without being woken up. And like for someone who has bipolar disorder, it's, it's like a strong recommendation, like right. These hours would be better. And that will do that's our best bet to prevent the postpartum psychosis. And so, I mean that's, and then for most people in that situation, they're feeling like even if they wanna breastfeed, they understand that, you know, we gotta prioritize the mental health above that, but for depression and anxiety as well, it's very preventative and and you can still breastfeed. So that's what I learned in midwifery school that in those first few weeks, it's so important that you feed on demand and that's how the milk is gonna come in. And that nipple confusion is a real thing. And it is, but this is just my sample size.

Tanya:

It is, but it isn't.

Rebecca:

Have in my practice now it's about 500 patients that we have in our practice. And we all pretty much say this because we, we do, we're honest that you may have nipple confusion. You may risk something with breastfeeding, but we're gonna put your mental health first. And this is our suggestion, but most of my clients still breastfeed and do fine. I mean, sometimes they need some help. And sometimes they decide it's not worth the stress of breastfeeding, but the mixed feedings with getting the five hours of sleep, I haven't seen it be a problem. And I've seen just great benefits from that.

Tanya:

I totally agree. I'm gonna roll it back just to drop, because I feel like there are probably people listening who are hearing this like five hour thing and they're going, oh no, I've been doing it all wrong or wait, that, wasn't what I was planning on doing. So I just wanna back up and talk about the people that are doing well. people who are doing well history or not. You're coping, you've got your supports in place and all of that. I'll tell you what I tell people that I'm curious if you wanna tweak that or add to it. But I basically start from a place of trying to get people to get accumulate approximately two hour chunks of sleep, because that's the reality for most new parents that are trying to feed on demand, breastfeed on demand. And I have them aim for eight hours within the 24, knowing that they probably won't hit it initially, but that's where we're fighting for it.

Tanya:

So we're going for maybe 2, 4, 2 hour chunks, right? Simple math, if that is not working. And I see like an escalation and symptoms now I shift and I say, we need a four hour chunk and someone's gotta take care of the baby. So you can get a four hour chunk. I wasn't saying five, but I was doing four, four hour chunks. And then I see if I get improvement out of them with naps around that, but at least one, four hour chunk. And we kind of figure it out. Cause I feel like some people can accumulate sleep and survive and some people have to have it consecutively to survive, but I don't know who's who, yeah. So I start in one place shift to the other, if we don't see a difference. And then from there we start to up the ante and start talking about prioritizing mental health over breastfeeding from there. So that's kind of my trajectory with somebody who starts out normal, but isn't coping over time. How does that sound?

Rebecca:

Sounds great. Yeah. I wish somebody had told me that when I had my first

Tanya:

Don't we all right. I

Rebecca:

Thought when I had my first, I mean, I was a labor and delivery nurse, but I thought, and I don't know how I'd been a nanny as well. I thought the baby was going to just start sleeping really well at some point, like going from waking up every two hours to like sleeping all night, I thought, when is it gonna happen? And I mean, it does happen with some babies like that. Right. But not with mine, And I,

Tanya:

And not, not all right. I mean, it's, it's the variation of normal is so huge. Yeah. And so I talk to people also about this is all possibly normal behavior. It's most likely normal behavior. It's a question of what you can cope with. Yeah. How well can you cope under these circumstances? And that's where my love of pediatric sleep coaches has grown immensely because I used to think that this was like froo-froo science, but I now know that when we are trying to help people prioritize their mental health, we can pull out a million different tricks to fix the sleep situation, to make sure that we've got that intact so that we know what we're looking at around the edges, that's kind of where I'm coming from on this. Okay. I actually wanna back up for one second, cause we breezed over just just a little bit, but I think it all comes out in the wash, but we breezed over postpartum depression a bit in our shifting from baby blues and postpartum psychosis kind of over into anxiety and talking about how they overlap.

Tanya:

But there's one thing that, look, I don't actually care if somebody calls it straight depression, postpartum, depression, period. It's like it's depression. Sometimes I think all of our words confuse everybody more. Yeah. Yeah. But, but when somebody is depressed in the I'm saying postpartum period, I wonder if you would say in pregnancy as well, there is one symptom that I think is different than what people experience when they're depressed outside of pregnancy and postpartum, and that is rage. And I wondered if you could speak to this feeling of rage that so many new parents can understand having felt, but not ever having understood it in the context of being symptomatic possibly of depression.

Rebecca:

Yeah. That's a great point. Yeah. Rage is something that I find in is yeah. Is a very common symptom of postpartum depression. And when I said anxiety is more common, I mean, I do see that as the presenting symptom more often, but postpartum depression is extremely common and thankfully our treatments are getting better and better. But rage to me really signals and overwhelm. So it's usually just, people are there's too much and there's not enough support. And so I find that the group support that we have in my practice and there's a lot of online group support and postpartum support international, who I love.

Tanya:

Shout out

Rebecca:

Many amazing specialized groups. And that's such a great place just to be able to get out what it is that the rage is, is surrounding. You know, is it about like feeling like your partner isn't doing enough? Is it feeling like you just never get any time to yourself? But yeah, it you're right. That it's not a symptom of depression that a lot of people experience or may have not experienced. And then also where do they put their rage? Because usually, you know, when people are holding onto anger, I'm asking like, well, where, where can you let it out? And when you have a new baby or a growing family is really hard to find that time for like intensive exercise is a great place to let your anger and rage out or journaling just going out with a friend. But those are things that sometimes we just don't have the space and time for. So making, I mean, I've most people tell me, I mean, group support for when I was looking at your list of things we were gonna talk about and you said, what is the magic bullet? And I'm thinking like, there is no magic bullet, but if there is, it's probably sleep sleep and group support. That's, that's what I would say.

Tanya:

I wanted to ask Rebecca very specifically, you know, what she feels is the most underutilized therapeutic option for the prevention and treatment of perinatal mood and anxiety disorders. And clearly we have been like sounding the alarm on sleep, and Rebecca's been like throwing in this little teaser about groups and I've been like, Ooh, I can't wait till she talks about groups. Yeah. So yes, I think everyone got the memo on sleep. So now I actually, I want you to tell us how you got down this path of being so passionate about groups and then tell us a little bit about your groups and why you think they're so effective. Cuz.I send people to postpartum support international and find them, their groups all the time, but I've never been in one. It's like it's coming from my gut that I believe this is right, but I've not had this experience myself.

Rebecca:

Right? Yeah. I didn't either. I mean, I had kind of a, a naturally occurring group, which I've realized, you know, during the pandemic times is certainly one of the things that has been lacking and why the online groups have been so important. But we had a naturally occurring group on my block in Brooklyn because the woman at the laundromat connected all the new moms on the block and she gave us, you know, there's phone numbers and we all started just hanging out in the park together and talking about what were, what were we worried about? What was our rage directed at? But I got interested through postpartum support international which is the website's postpartum.net. And I got interested. I was a midwife at a city hospital in Brooklyn. And the stigma about mental health was a huge barrier. So there was, there's a whole lot of directions that went in for me, but I was just thinking, you know, how can we make mental health a welcoming environment?

Rebecca:

How can we make this something that people wanna do? So through what I was learning through PSI I decided to start a group in our city hospital and I was lucky enough to get a grant. And through the grant, cause I wasn't a therapist yet, so I didn't lead these groups. I found therapists. So we paid them through the grant, but we also served lunch and the lunch was actually a really important part because it made it like a social experience. And also people would come early and they would hang out late and that's something I really miss about cuz now I do mostly online groups. I do miss, like we would people coming in and just hanging out for a little while and afterwards it was so great. But what I learned doing those groups at the hospital and I was really the administrator of the groups, but my midwifery patients were going to the groups.

Rebecca:

I mean they just, their moods improved. Look it usually after two groups, people feel better and they often have to compliment it with something else as well. But just that feeling of like I'm not alone. Other people are feeling this pregnancy. Isn't always a happy time. And being with others, going through the same thing, almost always the mood improves within two groups. Sometimes the first group people feel more anxious, but I always tell them, come back after next week, you won't feel that way. So it also was an entry way for people yeah. To feel like the mental health world doesn't have to be so scary and stigmatizing. And it doesn't have a punitive feel to it at all. And it's like, well usually, you know, I start every group talking about this is the space of non-judgment. So no judgment about anything about breastfeeding, about sleep or sleep training or not sleep training about what you wear about, you know, anything.

Rebecca:

And that, so that's very helpful to have a place like that. It can be a starting point and then people who may, who need more therapy or who could benefit from medications, they hear about that from other group members. So it feels a lot also, you know, be stigmatizing to talk about medication in that way from other people, not just from your provider, telling you about it, but from others who are making medication. So what we have at Brooklyn parent support is a Sunday group. Sunday is at 4:00 PM. That is a free and open group. And that's pretty much the same model when I was at the hospital that it's a drop in situation. We do some screening because it's not appropriate for everybody to start in a group. I think groups can help everybody, but some people need a different place to start.

Rebecca:

And sometimes like when it's related to birth trauma, it can be too overwhelming to start with group work. So we do some screening and some education. But that group is it's totally non, you don't have to have any commitment. So many people stay in the group for a year or longer, but some people come five times, some people come twice. And and that group has now been running for about three and a half years or so. And then we have, I have a therapy group where people sign up and it's a group of right now we have seven. And I was saying, some people are having their second babies who are within that group. And that's a closed group where the same group of people come every time. And so that's a more in depth. That's really similar to individual therapy, the kind of work that people are doing.

Rebecca:

And then we also have black and Latinx group that is a closed therapy group as well, led by Clarissa and Gabby who worked with me. And that group, we received funding from PSI actually. And that's been an amazing group that people we've just gotten such great feedback about it. And then we also have medication groups, which are totally different than our support groups, but I'm trying to model it on the centering pregnancy model. So people are coming as a group for their medication management. So they'll have an individual intake people who are either pregnant or postpartum, but they doing pretty well. So we're not gonna be making major changes in the group. But it's been really nice because people are talking about their medication with other people who are taking sometimes the exact same medication. And then we've been really enjoying that. So those are all of our groups.

Tanya:

So are your groups I know you said the Sunday group is a free group, but I'm assuming your other groups have a cost associated with them. Do you work with insurance companies to run groups? Tell me about that piece of it.

Rebecca:

Well the, the black and Latinx parents group is free through the funding of PSI. But we also, and then the Sunday, my Sunday 4:00 PM group is just totally free group, but I do bill insurance for group therapy. So we take a lot of insurance not every insurance, but as many as we can. And we do bill insurance for group therapy, which is unusual in a private kind of practice like ours, but is worked really, really well. And then, I mean, we have a, a fee and a sliding scale fee as well for people who aren't able to pay the price of the group, which is $50 per group or sliding scale if we don't take the insurance. And the med group, part of the reason we started that is that we don't take every insurance. And so the medication group is for people whose insurance that we don't take, but some people have just decided they like it better. It's just, they enjoy it and they find it. It's very supportive.

Tanya:

And so from the consumer perspective, when their insurance, when you accept their insurance and it covers the group, are they paying you their standard copay that they would pay if they were going to one on one therapy or is there a different way that this works out?

Rebecca:

They, yeah, they do have to pay the copay for their for their insurance, but for telemedicines still a lot of the, a lot of the insurers are still waving the copay. Some of them are waving the copay, some of them aren't. But usually the copays are not too bad, but it's the same as like a medical visit. So it's often like $20 or $5. Some people is $30.

Tanya:

And is your practice hyperlocal, Brooklynites, or do you work throughout New York state or beyond given the way telemedicine rules change during COVID?

Rebecca:

We work with New York state? Yeah. All, but it depends on the, you know, if it seems like it would be better for someone to be local, then we help find them referrals in your area. But in the groups, a lot of people are throughout the state and we have a lot of long island care, so we are Brooklyn parent support, but we're, we're not hyper local.

Tanya:

Okay. Got it. So I find it interesting that your, you know, your silver bullet in terms of group care, kind of overlaps with my silver bullet and my silver bullet is community. And that, that is why I think, look, maybe I'm wrong. And maybe the rates of postpartum anxiety and depression have always been, and they were just severely under reported, but I have a feeling that they have amped up over time. As we have moved away from our families, started living really solo lives. Nuclear families aren't even structured the way nuclear families once were. There's just so much pressure in the world to perform, to make a certain amount of money, all of these things to work hard and work endlessly, and we're all up against that. And in doing so, I think we've really lost our communities. We've lost our villages and what you're doing with therapy is giving people access to a community, to a village.

Tanya:

And I find that so beautiful. And I feel like we'll never really know whether it's the therapy or the community or both, but who cares? Cuz we know that they both have great value and you're doing both at the same time and I love that that's your model and your framework and you know where you're putting most of your energy. I think that's so cool. And I really didn't know that until this conversation. So I mean I've seen flyers and ads for your groups, but I did not quite get the extent to, with which you were putting most of your eggs in that basket.

Rebecca:

Yeah. We try for everybody. Who's seeing us for medication. We strongly encourage group and it's not for everybody, but it is for most. And sometimes people say I'm so I'm too much social anxiety and that's why I don't want to do it, but so great for social anxiety. Cause now in a safe place where other people are feeling the same thing, but our intake coordinator, who's wonderful. She's lovely. And she was a former headstart teacher before she worked with us. So she's just so used to working with parents. And she just, she sells the group to everybody, you know, and, and you can start right away. So if we can't see weeks, people can start group on Sunday and start getting some information. But I also love it. I mean, I love it for how effective it is cause I see how much group helps, but I also just really, it's fun for me too. Yeah. And it's just group therapy works so well and it's just amazing if you let the group do its thing, it all works because that's really group therapy is letting the group do the work of therapy and it just happens. You know, I don't have to do all that much. And sometimes people are really, you know, seeking information and wanting advice. But when we go beyond that and just sit with the emotions that are in the group, it's really magical.

Tanya:

Super cool. I'm so proud of you. And I'm so just thrilled that I've gotten to watch this journey of yours and that you came on my show today. Thank you so much. Can you tell everyone how to find you? Everybody needs to be following you on Instagram, if nothing else.

Rebecca:

So our website is Brooklyn parent support.com and Instagram is at Brooklyn. Parents support

Tanya:

All one word, no weird little underscores underscores Brooklyn. That's what I thought.

Rebecca:

Underscore support. Thank you.

Tanya:

You're welcome. I, I, I didn't have that memorized, but I kind of could picture the underscores and I was like, I have a feeling there's something else going on there anyway. It'll all be in the show notes. So it'll be easier for people to get to. Anyway, is there anything else that you feel like we're Remis in not having said in this little primer?

Rebecca:

No, I think, I mean, it's a great introduction. And I mean, I think the piece about medications is just so individualized, but there's there's very few medications that I would say, you know, are absolutely not able to be used in pregnancy and lactation. So seeking consultation if you're taking medications or did in the past is really, really helpful with someone in perinatal psychiatry. But I also just wanna thank you for doing this podcast and doing the work that you're doing, because it's just so impressive and amazing, and I'm really glad you're doing this.

Tanya:

Thanks, Rebecca. I love that there's a small and growing group of us midwives who are out there doing interesting things and kind of branching out because I don't know how you felt when you decided to do this. I don't think you felt this way, but when I decided I was not gonna work as a normal, like full scope, full time midwife, I for a little while, felt like I wasn't a midwife anymore. And then I had to remember that I'm still a midwife. Like I'm just wearing a lot of different hats and trying a lot of different things to get our voices heard. But I, there, there seemed to be more and more of us doing interesting things and specializing and interesting things. And I'm looking forward to having all of you on this show. I don't know if everyone can hear this, but there is like a major storm going on. So I'm like, oh no. Are we gonna get cut off? Do you hear that thunder? It's really coming down. Okay. so before I lose power, I'm gonna say goodbye. Thank you so much, Rebecca.