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We sit down with Alan Lindemann, an obstetrics-gynecology physician, to delve into the intricate world of postpartum depression (PPD). With over four decades of experience in the field, Alan offers invaluable perspectives and advice on navigating the complexities of PPD and discusses the evolution of understanding PPD, dispelling common misconceptions and highlighting the importance of inclusive family dynamics in managing this condition.

Alan Lindemann is an obstetrics-gynecology physician and can be reached at LindemannMD.com, doctales, and Pregnancy Your Way. Follow him on YouTube, Twitter @RuralDocAlan, Facebook, Pinterest, Instagram @ruraldocalan, and Substack. He is the author of Pregnancy Your Way: Choose a Safe and Happy Birth.

He discusses the KevinMD article, “The surprising truth on how to avoid postpartum depression.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Alan Lindemann. He’s an obstetrics-gynecology physician. Today’s KevinMD article is “The surprising truth on how to avoid postpartum depression.” Alan, welcome back to the show.

Alan Lindemann: Yes, thank you very much, Kevin. I’m happy to be here.

Kevin Pho: So Alan’s been on multiple times sharing his expertise on all things obstetrics-gynecology. Go to KevinMD.com/podcast to search for his name, story, and prior episodes. Today we’re going to talk about postpartum depression. The KevinMD article is “The surprising truth on how to avoid postpartum depression.” So for those who didn’t get a chance to read your article, tell us what this one’s about, Alan.

Alan Lindemann: Well, there’s a lot of people now who say that postpartum depression is mysterious and surprising, and I think it is neither. We’ve written a book recently, devoted a chapter to that. Postpartum depression is really much simpler than what I think we want to make it.

I recently read an article about how to determine postpartum depression with a whole bunch of four different kinds of tests and four different kinds of antidepressants, and really that’s not where we need to be. What most moms want is to talk, and for somebody to listen, and that’s much more effective than taking dozens of tests. So listening is the way we avoid postpartum depression.

Kevin Pho: Now, through your lens as an obstetrics-gynecology physician, and you’ve been doing this for three, four decades before you retired, is that correct?

Alan Lindemann: That’s correct.

Kevin Pho: So through your lens, just tell us what postpartum depression is and how does it typically present?

Alan Lindemann: Well, I want to go back a little bit. We haven’t done a very good job of diagnosing postpartum depression. For example, our ICD-9 and ICD-10 codes aren’t very good. Psychiatrists don’t really have a specific branch for postpartum depression, and neither do psychologists, and certainly obstetricians don’t.

But I want to start with a couple little stories that might help our audience a little bit. Musicians were actually ahead of doctors when it comes to postpartum depression, and one of the first songs I remember was by the Rolling Stones. I think that was before you were born, no doubt. But they were talking, this is in the 60s, talking about mother’s little yellow helper. And if you ever listen to the song, it’s a perfect description of postpartum depression. The little yellow helper helps her make it through the day. So that was the way we used to treat postpartum depression.

I can remember years ago, when I was a third-year student, a very pleasant young woman came in. She had two children, a daughter, two, and a son, four. And she really did have postpartum depression, although she wasn’t diagnosed with that. But I listened to her, and her problem really was that she was fighting with her son, who was four years old, and the fight revolved around his getting dressed.

And so I asked her, well, what’s the problem? And she said, well, he doesn’t want to wear what I choose for him. I said, well, can you let him choose his own clothes? She said, no, he might wear plaids and stripes. I said, OK, fine, try picking two outfits for him and see if he’ll wear one of them without a fuss. So she did, and that worked.

And that was kind of surprising to me, because I had two children of my own at the time and they would never have gone for that. But this kid was actually relatively calm and he went for that. So listening and responding with an appropriate answer really works very well for the diagnosis and treatment of postpartum depression. A lot of it is very practical.

I have another story to tell you. We think that postpartum psychosis is deadly, and of course it can be deadly. But years ago, this is in my first practice back in 81, this lady came in, she apologized, she was late, and I asked her why. And she said, well, I couldn’t take the bus today because people could hear my thoughts.

Well, that’s a psychosis, but it’s a benign psychosis. I asked her how long she’d had it. She said since the birth of her seventh child. Well, that was 30 years ago. So she had had this psychosis for 30 years, but it didn’t hurt anybody except her. So postpartum psychosis doesn’t always have to be dangerous, although it can be.

I think we’ve talked about this before, but there’s a story on ProPublica, a lady, her first name is Lindsay. She’s a nurse, an OB nurse, three children. She had a five-year-old daughter, a three-year-old daughter, and a seven month old son. But she was still getting up every two and a half hours with that son to nurse, and then she was getting up at 5:00 to do yoga.

Well, one day she took the kids to the doctor in the morning, and in the afternoon she strangled all three of them.

Well, what happened? She had gone for three months for psychiatric care. She had been on 12 different kinds of antidepressants. She’d been hospitalized twice. And three weeks before she strangled her children, she was in the hospital for three days, was given the diagnosis of generalized anxiety disorder, or GAD. Well, that obviously was the wrong diagnosis. She certainly had postpartum depression.

But if somebody had been able to listen to her for just a short amount of time, and if they had understood how postpartum depression works and how it gets out of control, they would have seen, you can’t be nursing a seven month old every two and a half hours. You can’t go to bed at midnight, wake up at 2, wake up at 4, wake up at 5. That’s not going to work. You can go crazy just by not sleeping enough.

So somebody should have been able to tell her somewhere along the way, this is not what you should be doing. You should be sleeping three, four hours at a time. If the baby has to eat in the night, maybe you share that work with your husband, who should be able to get up one time a night. But the point is that by seven months that baby ought to be sleeping four hours at least, if not more. So she had a completely crazy schedule which nobody had identified.

And now Lindsay, she tried jumping out of the second story of her home, and of course she didn’t kill herself, she just broke some bones. So now she’s up for manslaughter and probably murder. Well, should she be guilty? How guilty should she be? It’s not as though she didn’t go for help. Besides that, she had told several of her doctors and her husband that she had voices telling her to kill her children. That’s a medical emergency, and somebody should have paid attention to that.

So yes, a previous depression is a risk factor for postpartum depression, but most postpartum depression is very situational. So if you have a crazy schedule, you ought to be able to go someplace and have somebody listen to you and give you some reasonable advice.

So to me, and you ask how do you prevent postpartum depression, well, this is how you would treat it, early and treat it well. But preventing it is a little bit different manner, but it’s probably actually easier.

Years ago I just had fun talking to my moms and dads. The dads are always invited to prenatal care, and so are the children, and that’s an opportunity for everybody to bond with that baby before it’s born. It’s also a golden opportunity for a doctor or a nurse to listen to mom and dad and see whether there’s some problem that might be coming up that would easily be avoided by a little bit of listening and a little bit of talking and answering the questions that they have.

Kevin Pho: Now, what are the risk factors? You mentioned depression, pre-existing depression, as one that would predispose a mother to postpartum depression. You talk about in your article unrealistic expectations for new parents as also a potential factor. So talk more about that.

Alan Lindemann: You’re right, absolutely. Thank you for bringing up that point, Kevin. It is the main problem.

And so how does that manifest itself? Well, one of the reasons I like the example of Lindsay is precisely because she had one unrealistic expectation after the next. For example, she was going to be super. Well, none of us is super. We all need sleep, we all need some kind of a sensible schedule.

So an unrealistic expectation, life isn’t going to change, that is a real big problem. If you go into postpartum thinking that nothing is going to be different, or thinking that you’re going to be super, you really have a lot of trouble. The thing about a good postpartum adjustment is that you know life is going to be different, and you know what you’re going to have to do to make those adjustments.

Like for example, we used to be able to, when we left the hospital after birth, we could have three, four, five days, and everybody, we used to have rounds revolving around this. We’d go with the nurses, go with several students, residents, and descend on the patients. But what we would know and learn is who was ready to go home. What were they thinking? How were they adjusting? Was baby eating OK? Was the milk coming in, or were they successfully feeding with the bottle? So we actually made sure that people were ready to go home.

Today that doesn’t exist. We have insurances going nuts getting patients out of the hospital after 24 hours, because they think they’re going to save money, when indeed they don’t save any money that way, because the hospital doesn’t run empty, there’s still bills you have to pay. So you don’t really save much money.

And the thing about it is, if you look at which babies return to the hospital for failure to thrive, it’s babies born to moms who are let out of the hospital after one day. In other words, they’re not ready to go home. This group, that is the 24-hour stay or less, is twice as likely to have babies hospitalized for failure to thrive at four, five, and six months as the moms who’ve had C-sections and who get to stay in longer.

So we’re not saving any money, and we are causing harm by having a very short amount of stay. Well, instead of the three days or four days or whenever, we throw 20 CDs at them, and that takes the place of getting them ready to go home. So the whole system doesn’t work. It doesn’t work as well as it used to for people.

But yes, postpartum depression should be preventable. We should, for most people. And in the event that it’s not prevented, early treatment is recommended. I mean, it can be done. Lindsay is a perfect example of the treatment that didn’t work.

Kevin Pho: So what are you saying is the intervention that we need to change today, that you see isn’t happening as often as it should? Is it simply just listening more to the mom? What specific changes would you make?

Alan Lindemann: OK, thank you. In the first place, and this should be an easy change, Kevin, but it’s not going to be easy, but it could be. For example, if ACOG would simply say, enjoy the prenatal visits, bring the family in, bring the kids in, bring dad in, sit down, spend 15 minutes with them and listen to them, that would go a long way. And of course you’d have to be able to listen and give them the correct advice, like, you’re going to have to make some postpartum adjustments and these are the adjustments you need to make. So that would be easy.

Instead, what we’re doing is throwing a bunch of tests at them. ACOG has decided now to make two visits instead of one. Well, that’s really a very small concession to make, because what moms, dads, and babies need is the whole year, or sometimes maybe more, like my first example, 30 years. She should have had some kind of attention. So that would work.

Another thing that we’re trying to do now is having doulas do telemedicine postpartum. Well, that might actually work, but I think it’s the physicians who ought to be listening and who ought to be investing in our patients.

Right now, if we look at maternal mortality, the number one cause of maternal mortality is what we call behavioral. That would be suicide, homicide, and drug overdose. Now, the real big problem with that is there are a lot of doctors who don’t feel that they are responsible for that, and maybe they aren’t, but let’s not argue that point. Let’s simply say that the prenatal visits are a wonderful adjacency to the postpartum course, and it doesn’t matter whether you feel responsible for it or not. It is an opportunity which is, at the present time, mostly being missed.

So these solutions should be simple, but who’s going to give first? I couldn’t tell you.

Kevin Pho: So simple but not easy. And you’re saying the reason that this isn’t happening is because of the focus on the business aspects of medicine that detracts from that relationship. Is that right?

Alan Lindemann: Absolutely. There are so many things today that interfere with the patient and doctor relationship. One is the electronic record. I’m old enough to remember when a patient came in, you listened to what they had to say and you tried to make an appropriate response, and you sat down and you looked at them in the eyes, you had eye contact.

Today, at least half of the time, when you go in, and I’m a patient now, and I have a good doctor, but half the time he’s looking at the computer. So I think that’s a tremendous problem. When I was practicing, I didn’t like to look at the computer, so I did the computer after work and on Saturdays and Sundays. But it just made a lot of work out of things. And I do think that there are a lot of people today who think there’s nothing wrong with not establishing eye contact and not getting feedback from your patient.

Kevin Pho: We’re talking to Alan Lindemann. He’s an obstetrics-gynecology physician. Today’s KevinMD article is “The surprising truth on how to avoid postpartum depression.” Alan, as always, we’ll end with your take-home messages to the KevinMD audience.

Alan Lindemann: Well, thank you, Kevin. Listen. That would be my advice to physicians. To patients, I’d say try to find somebody who will listen to you.

And of course we do have our book, “Pregnancy Your Way: Choose a Safe and Happy Birth.” We spend a lot of time in that on postpartum depression and how to avoid it, and that’s one of the reasons we wrote the book, is to try to make up for the things that used to be but no longer are.

Kevin Pho: Alan, once again, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Alan Lindemann: Thank you.