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Mother Shift Navigating Perinatal Mental Health Challenges with Esther Rollhaus, MD

• Alisa Minkin

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In this episode, Dr. Esther Rollhaus discusses the exciting but challenging stage of becoming a mother(matrescence) and the psychiatrist lens on perinatal mental health challenges.
Dr. Esther Rollhaus is a medical doctor with specialties in
Child, Adolescent and Adult Psychiatry. In addition to her
private practice, she serves as a Consultant on Reproductive
Psychiatry at Achieve Behavioral Health, a mental health clinic
for the Orthodox Jewish community.
A graduate of Stern College for Women with degrees in
psychology and English, Dr. Rollhaus was accepted into the
prestigious Icahn School of Medicine at Mount Sinai, one of
only a handful of medical students selected specifically for
their liberal arts background. There she received an award for
Distinction in Medical Education, the first of many awards
throughout her distinguished career.
Dr. Rollhaus has held consulting positions at Montefiore
Einstein Psychiatry Associates, Under Five Trauma Services,
Jack D. Weiler Hospital, Montefiore Medical Center, and has
taught in multiple adjunct professorships.

Her original research includes investigations into culturally competent care for Orthodox Jewish
patients and the benefits of teaching medical students skills for trauma-informed care.
Among her many areas of expertise, Dr. Rollhaus particularly enjoys speaking on women’s mental
health throughout the lifespan as well as more specific topics related to psychiatric conditions. She
has presented on the impact of a mother’s postpartum depression on young children, suicide risk
assessment, ADHD, bipolar disorder, infertility, and the impact of medications during pregnancy.
With a special gift for making complex topics digestible, Dr. Esther Rollhaus is an enthusiastic
addition to professional conferences, community workshops, panel presentations and guest lectures.
Whether your group is made up of healthcare providers, community members or students, Dr.
Rollhaus uses compassion, humor and relatable examples to teach audiences of all sizes why we need
to understand and prioritize women’s mental health.
Just as every woman has unique healthcare needs, every event has a different agenda. Dr. Rollhaus
customizes all her talks. She welcomes questions and wants to hear your needs to ensure she hits the
right note for your group. With Dr. Rollhaus at your next event, you’ll deliver a transformative
experience that sparks conversation long after the session ends. For more information, visit
ChildandFamilyPsychiatry.com/Speaking.

Her continuing education course, "Hormones Are the Headline,"is now available on her website https://www.childandfamilypsychiatry.com/online-courses

Cover art by Charlotte Feldman
Please note that while I am a pediatrician, I am not your child's pediatrician. This podcast is for informational purposes only and does not constitute medical advice. For any medical concerns or decisions, please reach out to your child’s health care professional.

Welcome to Kids Matter. I'm Dr. Elisa Minkin. As a pediatrician, mom and grandma, I understand how challenging it can be to help our kids grow into their best selves. We are so much more powerful together. Here I will be sharing the knowledge and wisdom of a wide range of people who understand and care deeply about children. I'm hoping for your input as well because kids really do matter. They are our future.

Alisa Minkin

Welcome back to the Kids Matter podcast. I'm really honored and really excited to have Dr. Esther Rowhouse here with me today. Dr. Rowhouse is a reproductive adult and child psychiatrist in private practice in Riverdale, New York, and via telepsychiatry to New York and new. She has particular interest in women's mental health, infertility and pregnancy loss, and peripartum mental health. A sought after seeker. Dr. Rowhouse translates complex clinical and research topics into accessible, practical content for a range of audiences. She has taught medical students, trained interdisciplinary healthcare teams, presented at conferences. Community events and professional organizations. Her continuing education course hormones are, the headline is now available on her website, which I'm going to link in the show notes child and family psychiatry.com, and you can look into online courses on that website. So this is really important. I've been looking for a reproductive psychiatrist ever since I started working on the topic of perma Perinatal mental health disorders with the perinatal mental health therapist in my community, Danielle Mizrahi, whose second episode is actually. Coming out tomorrow as I record this today, so by the time people hear this, two episodes will have been released. But I needed to speak to a reproductive psychiatrist because it's a different lens. I really needed that lens. We could not talk about, for example, the role of medication and it's still even putting aside medication. Your lens is still. A different angle that I needed to capture. I'm going to link to the show notes also my first interview with you, which is for the Jewish Orthodox Women's Medical Association or Jona podcast called Women Are Not Just Small Men on all the Hormonal Changes Through the Women's Lifetime. We are specifically focusing on what we are now calling match resin. I did not know that was a thing we'll talk about that today. But I'm really excited to be talking about this with you, and I wanna just start with having people understand what is a reproductive psychiatrist. And by the way, thank you so much for doing this with me

Esther Rollhaus MD

My pleasure. I'm so glad to be here, and I had such a good time when we talked on Joma and it's really great to be here. I listened to the episode with Danielle Mara, and I was in the car by myself and I was like shouting out and also this. So I'm really.

Alisa Minkin

one.

Esther Rollhaus MD

Yeah. Oh, good. I'm so excited. I'm so excited. So reproductive psychiatry it focuses on the brain and the hormonal system specifically through changes in a woman's life. So thinking about estrogen and progesterone as it affects the brain through puberty, through monthly cycles, through pregnancy loss, through preconception pregnancy. Postpartum and perimenopause and all of these are periods that happen to women that don't happen to men. They don't have these changes in historically psychiatry, which has been run by men, has neglected this part. And we've been thinking about neurotransmitters historically, but now as people are specializing in reproductive psychiatry, we're really starting to think about the roles of estrogen and progesterone on brain health and brain functioning.

Alisa Minkin

That's a great short explanation. And I mentioned metres, but I didn't define it 'cause I wanted YouTube. Please.

Esther Rollhaus MD

Oh, okay. Amazing. So this is a term that came up in the 1970s and then has recently been reclaimed by Lucy Jones. I have her book, by the way. I taught, brought a couple books with me that I've been reading since we, I heard that we were gonna do this podcast. We can link these in the show notes also, but these are amazing. This one.

Alisa Minkin

mom rage for people who can't see Rattled mom, rage and metres,

Esther Rollhaus MD

And Metre essence, ugh they're amazing and they're really bringing to light the experience of new mothers and thinking about becoming a mother as a developmental milestone. So we've heard of adolescents. That's the period of becoming, transitioning from being a child, towards becoming an adult. And what has historically been neglected is that there's actually a developmental process. In birthing an individual or in re becoming a mother, and that's an identity shift. That's a change in the way that society views you, the way that you view yourself. It's an opportunity for tremendous growth and sometimes an opportunity for growing pains, for significant growing pains.

Alisa Minkin

Significant growing pain. So we're gonna start with what's normal. By the way, I just read a book called another book, I dunno if I'm gonna link it or not, called Mom Flud

Esther Rollhaus MD

Oh, I like that.

Alisa Minkin

the, author of the book, maybe I will, the author of the book had postpartum depression and there was this image of her. On online at night watching those t tra wife, like in their gauzy gowns, and they're milking the cows with their beautiful children, and she's sitting there at night pumping milk because she can't directly breastfeed in the middle man. The pump

Esther Rollhaus MD

yes.

Alisa Minkin

and that image will stick with me. Like

Esther Rollhaus MD

Yes.

Alisa Minkin

how it's being portrayed right through social media, for example.

Esther Rollhaus MD

Yeah.

Alisa Minkin

And how it is in real life. So I wanna start with what we call the baby blues, because that's normal. We need to talk about what's normal and then we need to get to where you need to, seek help.

Esther Rollhaus MD

Yes. So the baby blues are normal and there are direct result of the hormonal changes that come from the increase very, the decrease, the very steep drop of estrogen and progesterone. So essentially a woman is almost going through menopause overnight, where she has the highest physiological levels of estrogen, progesterone she's ever going to have. At the end of pregnancy, she gives birth and they plummet down almost to a menopausal level at that point. Over 24 to 48 hours. And we know that estrogen, progesterone have receptors in the brain and they affect the neurotransmitter systems like serotonin, norepinephrine, and so we're actually going to see mood changes. For everyone during that time. So about 80% of women have what we call the baby blues, which is tearfulness moods, up and down feeling this overwhelmed feeling, which is both hormonal and also a result of taking care of a new life that is so overwhelming. I'll also say that I don't think we prepare women for birth enough. I think a lot of people go into this and, they think of holding the baby and that feeling of initial, of almost like romantic love with the baby birth is bloody birth. It can be traumatizing. It can feel really out of control. I'll say that I remember having this experience of oh my gosh, I'm leaking out of every orifice of my body. I'm sweating from the perimenopause. The milk is coming in. Crying from my eyes. Meaning, meaning like there's something a little bit more gory, I think than how we portray new motherhood in society.

Alisa Minkin

I almost entitle this. Enjoy every minute

Esther Rollhaus MD

Oh my God.

Alisa Minkin

say.

Esther Rollhaus MD

That's, my like, pet peeve phrase. Enjoy every minute that it's a really, okay, if you're not enjoying every minute, you, we just gotta get through this part. We really do because, and then that puts a lot of pressure on people. I think and this idea that you're gonna fall in love with your baby immediately, that doesn't happen for everybody.

Alisa Minkin

I really wonder about protective factors to not go from, which is what we're gonna talk about next, is actual perinatal mental health disorders. wonder you think about that, because one of the things she mentioned in Mom Fluence is she felt that the. Lack of support, I think, not if she mentioned lack of support, but definitely the social media expectations had an impact on her actually having postpartum depression as opposed to just the baby blues.

Esther Rollhaus MD

I wanna divide it into sleep and the physiological measures that people can take and psychosocial support. And then the cultural piece as well. So in terms of the biology, sleep, I would say sleep is the most important medicine we have. And often women are not getting enough sleep because they're the primary caregiver at night. They're either nursing or feeding at night. And don't have support. And that 3:00 AM loneliness is, can be devastating in addition to the fragmented sleep. So in general, to function optimally, like we're looking for at least five to six hours of consecutive sleep. Who has that?

Alisa Minkin

you're breastfeeding.

Esther Rollhaus MD

And every, you have to feed the baby every three hours and so those, yeah,

Alisa Minkin

wanna say something before I lose my train of thought.

Esther Rollhaus MD

go for it.

Alisa Minkin

This is how I helped my second daughter who had a baby. I said, you sleep and we're giving a bottle. And I think if you're thinking about breastfeeding and the perfect parenthood, you never give a bottle and your milk has to come in and you have to nurse on demand and she. Is doing really well with the nursing. She's so happy she's been able to nurse and she almost gave up,

Esther Rollhaus MD

Yeah.

Alisa Minkin

nothing wrong with taking that step back and getting that sleep that you're so been so deprived of at that point, just saying,

Esther Rollhaus MD

Yeah, no, and it's, and it helps the long-term outcomes for the most part. And so this isn't against breastfeeding. There are lots of benefits to breastfeeding, but a flexibility about how you're doing, whether it's a bottle, sorry, whether it's dad or somebody else bringing the baby to you at night so that they can feed from your breast, but you're not the one putting them back to sleep or the one who's changing the diaper at night.

Alisa Minkin

Your sleep is still being disrupted if you don't take a break at all from nursing, and the point that I was making is you can still nurse even if you take a break at some point you may need the break more than you need that particular nursing session.

Esther Rollhaus MD

Yes. Agreed. Agreed, agreed. So sleep being so important and needs to be protected especially for people who have a mental health, a history of mental health difficulties, that is one of the number one things that I talk about in terms of postpartum plan. So people have birth plans. It's throw those birth plans out, but you need a postpartum plan. How are you managing this?

Alisa Minkin

I never heard that. I love that.

Esther Rollhaus MD

Yeah. And we can talk more about what that looks like. The other thing is the psychosocial support. So that's amazing, that you go to your daughter and you help her sleep, right? And so somebody else taking care of some of the responsibilities over the 24 hour period. So let's say mom's up at night, okay? But dad does morning shift or grandma comes and she helps mom take a shower.

Alisa Minkin

You know

Esther Rollhaus MD

can't be underestimated in terms of the power of just helping mom eat, sleep shower, just like basic hygiene, all of those important things.

Alisa Minkin

This is why you need a village and I feel for parents who do not have that relationship say with their mother who can come help them who

Esther Rollhaus MD

Absolutely.

Alisa Minkin

money to pay for a doula or a night

Esther Rollhaus MD

Yeah.

Alisa Minkin

If you can though I do think that Americans are fiercely independent and think they should be able to do it on their own

Esther Rollhaus MD

And I think that's one of the lessons of mires actually, right? One of the developmental milestones in becoming a mother is going from an individual person who can take care of themselves. To having the experience of actually I am limited. I cannot do everything that's expected to me, all of me all at one time. And actually being able to accept help can actually be considered a developmental milestone. Yeah.

Alisa Minkin

Why don't I love this idea of the postpartum plan

Esther Rollhaus MD

Yeah.

Alisa Minkin

I dunno if you went through all the things I don't wanna interrupt you You

Esther Rollhaus MD

I will do one more. So society. Society, right? And this is where the issue becomes much larger than any one family where women are being told to go back into work. Sometimes two weeks postpartum, even six weeks postpartum, eight weeks postpartum if you have a C-section, right? You're lucky to get two months. And in terms of like lactation access, right? This is incredibly difficult to be able to be a new mother. And to go back to a profession or a career or a job so soon after having a baby.

Alisa Minkin

What again it's a matter of privilege right

Esther Rollhaus MD

I know. It is. It is everything we're saying. Yeah, everything we're saying, I, my recommendations are, get a doula, have breastfeeding support, have a mother who takes care of you. These are all, you're right, I'm, you're right.

Alisa Minkin

So I'm gonna say as a counterpoint that sometimes you have to just accept your reality and make decisions based on that And however pro breastfeeding I am it might be to not breastfeed so that you can get sleep so that you can go back to work It might be I'm

Esther Rollhaus MD

Yes.

Alisa Minkin

We have thank God in our country safe formula again I'm not anti breastfeeding but we have to be more promo than we're being already

Esther Rollhaus MD

That's right. And better Mom does. Better. Baby does. And so I think there's a dichotomy sometimes or false dichotomy that people make of, are you prioritizing mom or are you prioritizing baby? Of course we're gonna choose the new baby. But no, that's a false distinction where really the outcomes of mom predict the outcomes of baby. So how well is Mom doing really can influence how well the baby does?

Alisa Minkin

Absolutely And I don't know if you wanna talk a little bit about the perfect parent trap that I alluded to when I talked about mom fluent because I think we just have to say keep having to say that we have to put aside all societal pressures and be very careful with the messages we're getting from social media Because it's this concept of intensive parenting right now the mother is just chop liver and is expected to throw herself on the altar of motherhood no matter what

Esther Rollhaus MD

Yeah. And this historically hasn't been, this hasn't been how it's been historically.

Alisa Minkin

Right

Esther Rollhaus MD

we parented in groups back, back in the day, and there was a lot more support for women and fewer expectations, right? So the idea that mom needs to go onto the floor and play with baby. That wasn't there in the 1950s, right? Mom was taking care of the laundry in the house and those kinds of other things. I'm very pro going onto the floor with baby, but we have to understand that comes at a cost of something else. There are only 24 hours in a day. And so thinking about the expectations that filter into motherhood actually put on my website a journal entry that people can fill out. Helps them reflect on what's a good mom and what's a bad mom in their minds, because we don't, when you think of what a bad dad is someone who abandons the family, right? But what's a bad mom? Oh, she didn't pack lunch. She, gives them chicken nuggets for dinner, right? These are the societal messages that we get of what it means to be a good mom or a bad mom in our society, and the expectations are just too high.

Alisa Minkin

It's a book Bad Moms by the way but there's not a book Bad Dads

Esther Rollhaus MD

Exactly.

Alisa Minkin

upset on that You wanna talk just for a few minutes about your postpartum plan because I never heard that before and I love that And that to me anticipating the issues and being realistic I think is so proactive

Esther Rollhaus MD

Yep. So it's about sleep. What's your plan to get sleep? And it could be napping during the day. It can be, like we said, having more support at night, but how are you going to preserve your sleep? That's really important. And then a feeding plan of how are you planning to feed your baby? And I always tell people of plans are just that they're plans, okay? And we don't know all the factors that are going to influence what actually happens. And so if a woman has trouble breastfeeding, she, obviously, she can get support, she can get encouragement, but it is not a failure to not breastfeed your child. And I think so many moms feel guilt. I've seen so many moms start off their postpartum depression and anxiety episodes with breastfeeding di. And sometimes if we know that someone's at high risk for ps, which is postpartum mood and anxiety disorders, sometimes we'll be very proactive about our recommendations of whether to breastfeed or not depending on the circumstances.

Alisa Minkin

It makes so much sense And the basic idea is think about this before it happens Right is forearmed So I really do wanna ta talk about actual disorders

Esther Rollhaus MD

Yeah.

Alisa Minkin

let's go into them That's

Esther Rollhaus MD

Yes.

Alisa Minkin

actually

Esther Rollhaus MD

sure, sure. So what?

Alisa Minkin

announcement Prevention

Esther Rollhaus MD

yes. Yes. Let's talk about them. PA DS is the name for what used to be called postpartum depression. PPD, that's postpartum depression, has been in the literature, has been talked about, since the 1990s, the two thousands. But PMAS adds in the anxiety component. So that stands for Perinatal Mood and Anxiety Disorder. So the perinatal piece adds in that it's not just postpartum, that we have hormonal changes that start in pregnancy and depression and anxiety and other mental health conditions can actually start in pregnancy and are the biggest predictor of postpartum issues. So if somebody is struggling in pregnancy with depression and anxiety, they are at higher risk for struggling postpartum.

Alisa Minkin

Absolutely

Esther Rollhaus MD

yeah, and then it goes on.

Alisa Minkin

them before even before they became pregnant that's a whole

Esther Rollhaus MD

That's right. That's also very, oh yeah, let's, we should talk about that also. Like we should get

Alisa Minkin

because that's where you come in

Esther Rollhaus MD

Yes, that's where I come in. Yes.

Alisa Minkin

To have a reproductive psychiatrist

Esther Rollhaus MD

yes. Yes it is. So then the mood and anxiety disorders piece. So it's the depression piece and the anxiety piece. And generally they come together almost invariably, they come together. And what does that look like? For postpartum anxiety it can look like checking a lot on the baby, having difficulty sleeping when the baby is sleeping. Intrusive, obsessive thoughts about harm coming to the baby. Postpartum depression. What distinguishes it from the baby blues is a sense of lack of joy, lack of connection. Difficulties with feeding yourself, sleeping with those kinds of important like functional outcomes. Sometimes people have somatic symptoms, so body-based symptoms and so they be like, why am I not feeling well? I'm feeling dizzy all the time, or My stomach hurts all the time. And those can actually be symptoms of PMA ds where there's nothing physically wrong, but the distress is manifesting in in the sensations of the body.

Alisa Minkin

Absolutely And anxiety by the way I think I my experience is that anxiety is actually more common and that's an issue I have with screening because And pediatricians are supposed to and we do in my practice screen for It is not really PMAS it's really more postpartum depression and we're missing the anxiety that I find to be more prevalent and still very concerning

Esther Rollhaus MD

Yeah. And in society we are still talking about postpartum depression, and people will come in and they're say, I feel fine. Like I'm not depressed. I, I'm functioning, but on the other hand, I also can't sleep. I can't, I'm, like these kinds of intrusive, catastrophic thinking overthinking those somatic symptoms that we talked about that is under the umbrella of peds.

Alisa Minkin

Exactly So I think that's really important I wish that the screening took that into account

Esther Rollhaus MD

I know I think people are working on it to be fair. I think that there is more of a push towards that, and so I think the field is trying to get more to capture the anxiety piece.

Alisa Minkin

I'm also gonna say that I'm seeing some resistance for various reasons to the parent filling out the screen there's concerns for privacy They're not really your patient mental health has stigma There's very and also sometimes the insurance bills for it And they're like I can't pay for this so I don't wanna have to pay for it And I I get all of that And if you're one of those people please tell the clinician what you're going through because That was the whole point of screening We have very little time and if you it's hard for us to assess it Topic like that without a screen it's really much more helpful to have the screen

Esther Rollhaus MD

And the pediatricians are the ones who actually really spend the most time with mom's postpartum. They're going in and they're coming and visit, having the well visits for their babies. Pediatricians are the ones really to pick it up.

Alisa Minkin

right And what is first line treatment I

Esther Rollhaus MD

It's a good question. So usually it's psychotherapy. So usually you can go and you can have a, there are lots of evidence-based psychotherapies. For PAS what I recommend is that people go to specialists in this field, there actually are reproductive therapists, so people who specialize in this that I recommend reaching out to and PSI, which is postpartum Support International has a whole list serve of therapists that specialize in this.

Alisa Minkin

I must link to that That's really important

Esther Rollhaus MD

So important.

Alisa Minkin

I linked the first episode and not the second but really important but when you say a specialist I Danielle Raki is an example of

Esther Rollhaus MD

an example.

Alisa Minkin

who has specifically been trained in perinatal mood and anxiety disorders

Esther Rollhaus MD

Yes. There's actually a degree that I find very valuable. It's PMHC,

Alisa Minkin

right She has

Esther Rollhaus MD

yeah, exactly. And so when you see that after someone's name, that's a good indication that they've trained and been certified for, specifically for mental health issues. Related to women hormones and postpartum.

Alisa Minkin

And I'm gonna bring up that there's a couple of access issues here finding a therapist that has that specialty Just like finding a reproductive psychiatrist being able to afford it A lot of therapists especially specialized ones do not take insurance And then the time right You're sitting there you're already sleep deprived How are you supposed to have time for that Throwing that out there

Esther Rollhaus MD

Y Yes I'll say one thing that kind of emerged from the pandemic that I think I'm grateful for in terms of access, which is now states with telehealth now, states that historically haven't been able to be accessed, are able to be accessed by psychologists through something called spac, where when you're licensed in one of the SPAC participating states, that actually extends to about 30 other states. So that's wonderful. I don't, I'm gonna, I'm gonna give an example of New Mexico. I hope that's one of them. Like you're licensed in New Jersey, you get your license in New Jersey. Now you can reach New Mexico through telehealth. That's an example. And a lot of women prefer telehealth with their new babies. So hard to get out of the house. And I'm a huge proponent of telehealth for new moms.

Alisa Minkin

Absolutely ab and you should ask your insurance and you should make your insurance cover this because we're supposed to have mental health parody

Esther Rollhaus MD

Yes, we are. Yes, we are.

Alisa Minkin

So besides therapy what else do we have in our toolbox What do you have in your toolbox

Esther Rollhaus MD

so I have medication. I have medication, and what I'll say is that coming to see me does not mean that you're going to get a prescription. That's okay. It can just be a conversation. Reproductive psychiatrists are also experts in diagnosis and sometimes having a. Expert tell you, listen, what's going on for you? This is PMAS, right? This is something that we know it's biological, it's very real for you. Sometimes even that conversation can be helpful for people. Yeah, go ahead.

Alisa Minkin

I wanted to who should get medication That's my next obvious logical question

Esther Rollhaus MD

So people for whom psychotherapy is not enough people who are having functional disturbance, meaning that they're not able to do the things that they need to do. In the postpartum context, that's sleep. When the baby is sleeping, take care of themselves, nourish themselves, eat, get out of the house, have social relationships attach to the baby have excessive ruminative guilt. These are all signs that we need to escalate treatment. And medication is very, it's indicated for moderate to severe symptoms. And so you might even start with that even before psychotherapy. So if somebody can't participate in the psychotherapy because of how severe their symptoms are, then actually medication is a first choice. That's where you would start.

Alisa Minkin

That's a really important point because I do see a lot of parents trying desperately not to go on medication

Esther Rollhaus MD

I know. And it's the indicated treatment. It's the indicated treatment. And if we understand this as biological, a neurotransmitter mediated, then it makes sense that we're trying, that we actually are targeting what is like the biological factors there. And so I know that there's a lot of stigma about medication, a lot of hesitancy and a lot of guilt, frankly. About taking medications and I want, I wanna explain to your viewership really, like what this really means. What does it mean really to take medications? So for the most part, when we talk about medications, we're mostly talking about SSRIs, which are selective serotonin reuptake inhibitors. And they work on the brain to create more of the neurotransmitter serotonin. It. They're not, sorry, let me say that they're not making more serotonin, but they're preventing the cleanup of serotonin between the nerve cells, okay? So that there ends up being a net increase in serotonin. And what we find is that they're very effective in reducing anxiety, reducing intrusive thoughts, and reducing depression. And they really work. You have to be on them for long enough and you have to be on the right dose of them for them to work. But they are incredibly effective in treating pma.

Alisa Minkin

That's great summary and I wanna point out that you can go to your OB and get a prescription in terms of access I want your thought on who needs to go beyond the level of the ob because OBS cannot handle the entire spectrum of the premed

Esther Rollhaus MD

So your GP can do this, your OB can do this, and often what they'll do is they'll start a low dose of medication monitor, perhaps they'll increase it, but for the most part, they'll stop at a certain point. And people might need higher doses or may have more complex issues. And that's where you wanna go to a reproductive psychiatrist. So if the symptoms aren't getting better on, I'm gonna say, Zoloft 50 or Zoloft 100, and the OB is not comfortable continuing that as makes sense because it's not their area of specialization, then reproductive psychiatry can really very much help. I'll also say. We're talking about anxiety and depression, but anybody with a bipolar spectrum illness, in my opinion, should be at a reproductive psychiatrist. It's not the same disease and it ha carries a lot of risk for postpartum issues, especially postpartum psychosis. And so that needs expert care for sure.

Alisa Minkin

and that's before you become pregnant

Esther Rollhaus MD

Yeah. To start with a reproductive psychiatrist. Yeah.

Alisa Minkin

I think if you already have a significant mental health condition and you're already on medication before you even become pregnant it's really helpful to consult with a reproductive psychiatrist

Esther Rollhaus MD

Yes,

Alisa Minkin

though I would say if you just had mild anxiety and depression that wouldn't necessarily

Esther Rollhaus MD

I think you can acknowledge that it actually does put you at increased risk for postpartum depression. So even people who have had mild anxiety and depression in the past. Are at increased risk for peds compared to people who have not had any mental health history. That being said, often what happens is that they can go through the pregnancy and either it works out like super well or there is a relapse or there is there are symptoms, and then at that point they can come to a reproductive psychiatrist and work on those symptoms.

Alisa Minkin

Again it boils down to axis right In

Esther Rollhaus MD

I know.

Alisa Minkin

world you would do it because you wanna be proactive and you don't know what's gonna happen

Esther Rollhaus MD

yeah.

Alisa Minkin

or end of the spectrum of mental health concerns

Esther Rollhaus MD

Yes.

Alisa Minkin

for something like bipolar or previous history of the more severe end of the peds

Esther Rollhaus MD

That's right. Yes. And I wanna mention a couple of things. One. One is, that PADS also includes other conditions including perinatal, OCD, perinatal, PTSD, and postpartum or perinatal psychosis. Those are also other diseases that fall under PA Ds. So if I can say one moment just about perinatal OCD, so that is where people are having intrusive, obsessive thoughts that can't go away, and they often do something like a compulsion. To try to mitigate the anxiety, but the anxiety can't be mitigated and it keeps going in a cycle and a cycle. So a really important fact is that actually 80% of women have intrusive thoughts not related to OCD, just related to the peripartum changes in the brain where we're actually going to see loops and thoughts that can come in. And these thoughts can be highly distressing. They can be about harming yourself or harming your baby. They can be very graphic sometimes. With images people can actually see themselves harming their babies. And that is not pathological, that is an expected change. In metres essence, for the most part. Where it becomes a disorder is when it's persistent and when the person can't move on from it. And so they are thinking all they won't, and then they start to do avoidance behaviors so they can no longer hold the baby because they continue to visualize dropping the baby and then they're avoiding caring for the baby because of these intrusive thoughts. That's where it becomes problematic.

Alisa Minkin

That is incredible that you lay that out because Danielle and I did talk about that and she recommended the book I think it's called Real Moms Have Scary Thoughts

Esther Rollhaus MD

It's wonderful.

Alisa Minkin

gonna link a whole library here

Esther Rollhaus MD

Uhhuh and Karen Kleinman has done amazing work on this field,

Alisa Minkin

that's

Esther Rollhaus MD

bringing this to light. And it's very important for providers to understand the normal intrusive thoughts and the OCD intrusive thoughts and distinguish that from something that's dangerous. Like something like thoughts of harming the baby from something like postpartum psychosis.

Alisa Minkin

And I think I see that as the role of a therapist to be able to really sit down because again clinicians do not have enough time to suss that all out We don't right Accepted the level of distress of the parent if you see there's a certain level of distress right

Esther Rollhaus MD

I think sometimes reassurance though, can be helpful even in pd just for someone who doesn't have OCD but is having intrusive thoughts sometimes reassuring them that this is. Normal, right? That this happens to people, it doesn't confer a risk any increased risk of actual harm coming to the baby. Sometimes that actually in itself can be reassuring just having that psychoeducation,

Alisa Minkin

right Pediatricians we're really good at saying normal It's normal We can do that And that's why what you said is so incredibly important

Esther Rollhaus MD

right? Because for most of the people who are seeing you, it is normal, right? If that's the statistics, 80% of people coming to you and sharing these scary thoughts. You can reassure them

Alisa Minkin

What's a quick way to know that they're in the normal zone though for say a busy pediatrician

Esther Rollhaus MD

Uhhuh. I think understanding their level of distress of how often they're thinking about this. So is it taking over their lives? Is it leading to avoidance behavior? Are they doing some kind of compulsions, like checking to make sure maybe, perhaps assessing whether they're going to harm the baby over and over again. Those kinds of things, cue you into that. It might be something more than an isolated, intrusive thought.

Alisa Minkin

Someday we'll have a more comprehensive screen than the EPDS which is

Esther Rollhaus MD

Oh, yeah.

Alisa Minkin

screen that we have right now because

Esther Rollhaus MD

Yep.

Alisa Minkin

Hello

Esther Rollhaus MD

Yes. Yes.

Alisa Minkin

Okay so that's a really big problem So I wanna talk more about medication because there is resistance and I do think that resistance falls into two categories One is the resistance of taking it during pregnancy because no one wants to take any medication during pregnancy if they don't have to And one relates to nursing I think we're gonna have to put nursing on the back burner today cause I don't think we're gonna have enough time But I definitely wanna talk about taking it while pregnant and if we can get to it when they're

Esther Rollhaus MD

Sure, we'll try. We'll try. So I wanna distinguish between people who are on medications before pregnancy and people who need to be on medications starting in pregnancy. So essentially a new onset, PMAS or perinatal disorder, or the many people who are on SSRIs for anxiety. OCD, depression going into the pregnancy. The data on the pregnancy and on the drugs are the same, but the advantage of the people who are know that they're coming in on an SSRI can benefit from a preconception consultation so they can actually meet with somebody, talk about the medications, talk about the risks or benefits, sometimes optimize the medications before we're going into a pregnancy. The. I think you said no one wants to take medication if they don't have to. Yes, agreed. If they don't have to. But what we have to do is we have to weigh the risks of taking medication compared to the risks of not taking medication. And in many cases, we're talking about tremendous suffering from the symptoms of depression and anxiety that actually we know have negative impacts on the pregnancy themselves in terms of obstetrical outcomes and in terms of actually some of the epigenetic changes that we see. In fetuses who are exposed to the stress hormones related to anxiety and depression in Mom.

Alisa Minkin

Feeling stressed, just thinking about stress hormones.

Esther Rollhaus MD

Yeah, cortisol. It's a tough one. It's a tough one, and it really can change some of the epigenetics.

Alisa Minkin

Do not Google

Esther Rollhaus MD

I

Alisa Minkin

Okay?

Esther Rollhaus MD

no, don't Google. And this isn't meant to be, this isn't meant to be to blame anybody, right? So I can see somebody who's listening to this and they're like, I'm anxious and now I'm messing up my kid by being anxious. I,

Alisa Minkin

can't win.

Esther Rollhaus MD

You can't win. You can't win. You can't win.

Alisa Minkin

But you know what though? What I meant by don't Google is there's a very strong anti-medication

Esther Rollhaus MD

Yeah.

Alisa Minkin

going around and it's current and administration's people are not helping. Not to mention names.

Esther Rollhaus MD

That's right. There was a whole panel.

Alisa Minkin

Very problematic. Studies are coming out and people are saying, this is dangerous, medication is dangerous and bad. And then the mother is like, what am I supposed to do? Is it cortisol or is it Zoloft?

Esther Rollhaus MD

There are a lot of studies that are coming out that are showing the safety of these medications where the risks are incredibly low. And so what's challenging sometimes about assessing medications in pregnancy is our gold standard is something called a double-blind placebo study, where we have two groups, we give one an intervention, the other one doesn't get an intervention, and then we look at the outcomes. But for pregnancy, we have to do it retrospectively. Meaning that it's, we can't experiment on pregnant women of giving some drugs and some not drugs. And then seeing the outcomes, we actually have to look at the the outcomes in the children and then extrapolate backwards into whether the medication increased the risk of some negative outcome. So I'll give you an example. Let's say we wanted to look at the rate of pregnancy loss. We have to compare it to the baseline risk of pregnancy loss across all pregnancies, which is about 20%. What we see when we look at the moms who have been exposed to SSRIs is that it follows, it's about 20% the same thing in terms of risks of malformations or birth defects. The risk, the baseline risk in any pregnancy is three to 5%. And Reassuringly, when we look at the risk for baby who's moms have taken medications, it's tracking at three to 5%.

Alisa Minkin

So we don't have evidence that it is not increasing the risk.

Esther Rollhaus MD

Yeah. That strongly suggests that. Yes,

Alisa Minkin

We don't know for sure. And I think uncertainty is something that is really hard, especially when you're pregnant and you're trying to do everything right,

Esther Rollhaus MD

I know.

Alisa Minkin

it's also a reality and. recommendation is to not Google, find a clinician you trust and let them help you make the decision and then just do it as opposed to trying to agonize right, and to go into analysis paralysis and try to do that risk benefit assessment yourself.

Esther Rollhaus MD

That's right. And so really what the psychiatrist should help you be doing is really talking about risk versus benefit. I like that frame where, what's the risk of the medications and helping you go through all of the outcomes for the medications and comparing them to the baseline risk. Spoiler alert, actually, SSRIs seem to not increase the risk of any of the adverse effects that we can think of during pregnancy. We can get into the specifics of that, but for the most part, your psychiatrist should be able to explain to you the data that is essentially very reassuring on the SSRIs. They should also take into account your own history and the suffering and the distress and the functional disturbance that is occurring from the undertreated or non-treated mental illness. And then really emphasizing the benefit of women deserve to be they're not incubators they're autonomous human beings who need to function while pregnant and beyond. And so there's actually a lot of merit to thinking about how wellness can help somebody and help their whole community, help the baby. There, there's so much to that. Women deserve to be well.

Alisa Minkin

You said so many great things. I don't know where to start. One. One is women are not incubators. And again, the societal pressure treats us like Madonna, right? Like we don't matter. We're the vessel. And that's not true. You deserve to be, can we say that enough times louder for the people in the back. Number

Esther Rollhaus MD

Women deserve to be Well,

Alisa Minkin

you. You're not chopped liver.

Esther Rollhaus MD

No, you're important.

Alisa Minkin

So that's one thing, but another thing that I wanted to say about that was. So another thing is when you said risk versus benefit, that's really needs to be underscored because I think it's very hard, but it's true that everything we do has risk. So no one is saying that these medications are risk free. You have to acknowledge the risks because sometimes it's portrayed in order to get people to accept it as, oh, it's hundred percent safe. And then you wonder why we don't have trust.

Esther Rollhaus MD

I never use the word safe. Safe is not the word.

Alisa Minkin

Medications have the risks. They just have to be aside compared to the risk of not taking it. And that is a very individualized decision. So to underscore, again, in the age of, not just Google, but ai, You really need to have a clinician walk you through this because only they can help you take your individual situation under account, not your social media friends, right? Not Google, not your family, not anybody else.

Esther Rollhaus MD

Right.

Alisa Minkin

They don't have the objectivity and they don't have all the information.

Esther Rollhaus MD

And in the panel that we talked about from the authorities that we may or may not be referencing, the problem with it was that it didn't talk about the alternative of not treating. And so I watched the panel, I found it very scary in terms of these papers that are incredibly complicated and honestly misquoted or misinterpreted, but. What didn't the clinical approach was not, or the clinical factors was not actually accounted for in my opinion.

Alisa Minkin

Wait, what panel? Sorry.

Esther Rollhaus MD

Oh, this is, okay, so this is from the FDA. So the FDA had a panel about safety if medications in pregnancy. And it was a very it really was a scary panel and I can see how somebody would make conclusions to not take medications from it. But the problem was that it was skewed and then it didn't talk about the alternatives of not taking medications and it didn't talk about the suffering of women. It like whitewashed what. A PAS experience would be like yeah,

Alisa Minkin

It came from an anti-medication bias.

Esther Rollhaus MD

it did.

Alisa Minkin

you have to be so careful. And I understand the concept of someone who may feel that medications are being pushed by big pharma

Esther Rollhaus MD

Yeah.

Alisa Minkin

and don't trust the studies behind it. And I think that's why you have to have that individualized conversation and the clinician has to work with you because I find that some parents in my practice as a pediatrician are very hesitant with medications for their kids. And I work with them, but it does matter about the functional level,

Esther Rollhaus MD

it really does.

Alisa Minkin

Yeah,

Esther Rollhaus MD

does. And the urgency with which somebody needs help, sometimes we don't have time to, to, to wait or to try psychotherapy. Like sometimes there is an urgency if the functionality isn't is really disturbed, unfortunately.

Alisa Minkin

But to flip the script on that, just like I do for a family. Say the child has a DHD or mild anxiety and we're doing accommodations in school and therapy, we're not doing medication. The same can be true for a woman who goes through this and goes to her clinician, and the clinician just prescribes medication, but maybe they don't need it.

Esther Rollhaus MD

And there is some non thoughtful prescribing out there. And I can really relate and I can understand that this, these, that. That sometimes these decisions aren't well thought out.

Alisa Minkin

right. So trust your gut. When I say trust your clinician, you need to have that trusted relationship. And again, there's a certain degree of privilege that goes on here, right?

Esther Rollhaus MD

I know. I know.

Alisa Minkin

Because time again,

Esther Rollhaus MD

I

Alisa Minkin

time is the general practitioners, the obs, and the pediatricians big problem or lack thereof. So we've talked about a lot of different things. I think we have a little time, if that's okay with you to talk about breastfeeding a medication because that is a separate conversation.

Esther Rollhaus MD

So what I wanna say about breastfeeding is actually it's much more rea it's, I would say, lower risk in some ways because the infant is getting much less of the drug compared to the actual pregnancy. So when it's placental transfer. The drug is going through the bloodstream and it's going into the baby's bloodstream, but lactation actually involves a process of filtration. And so the infant is actually getting very little of the drug. And so we look at something called the RID, which is the relative infant dose of how much of the drug is the baby actually getting, and we use 10% as a marker to really think about the amount that they're getting as almost negligible. And so most of the SSRIs that we're talking about are well beneath the 10% mark. And so the baby is actually not even getting that much of it, what I tell. And then we also have to look at the clinical outcomes. And for the most part, babies are tolerating this just fine. It's one of the most commonly prescribed medications postpartum, and women are using it in lactation and we're not seeing adverse effects, like growth issues, or anything of that sort.

Alisa Minkin

That's really helpful to know. And there is a whole database and people can also lay, people can also access the database. I think it's LactMed is one of them. I dunno if that you need to be a physician for, but there's also, what is the one that's free and available is LactMed free and available.

Esther Rollhaus MD

I'm not sure actually, but I access, I guess so. I access Slack Met a lot. There's also mother to baby.org, which also answers questions about medications in pregnancy. And so you can type in the specific medications and get. Reliable information about that. Mass General also has a wonderful website that's geared towards patients themselves, where people can actually look up the data on each of the medications, either in pregnancy or breastfeeding. And so there are some very reliable resources out there. The internet isn't all bad.

Alisa Minkin

It isn't all bad, as pediatricians we get these calls every single day. Can I take this while breastfeeding? And we're fine with those questions. We wanna support breastfeeding moms with the

Esther Rollhaus MD

Yeah.

Alisa Minkin

That it is, can be quite not a hundred percent safe. Nothing's a hundred percent safe, but

Esther Rollhaus MD

Yeah.

Alisa Minkin

benefit is in favor. And that's really good explanation. There are other medications that people with PMA DS or preexisting mental health conditions might be taking. Are the whole range of them besides the SSRI safe on nursing.

Esther Rollhaus MD

So lithium is an example of a medication that is very controversial in nursing. And so I'm not gonna say a blanket, no, but that is something that would need to be coordinated with the pediatrician. The infants might need blood levels taken. Because they're exposed to lithium does get through the breast milk because of its chemical composition, and so that is more complicated. But for the most part, most of the drugs that we use commonly in psychiatry have very reassuring data.

Alisa Minkin

That's really good to know. I'm also thinking about women whose conditions possibly could be exacerbated by nursing. Is that a thing?

Esther Rollhaus MD

Oh yeah, it's a thing. Yeah. So we know about hormones influencing mental illness and there are hormonal changes that come with nursing. So in addition to the sleep issues that sometimes can come with nursing, there actually can be hormonal changes. Studies have looked at whether nursing, attenuates. PAS meaning makes CMAs better or causes PS and it hasn't been conclusive yet. But weaning we know actually can be a time of increased risk of PA Ds. So if somebody has been nursing, their hormones have been stable, to some extent, they wean, especially if they wean, suddenly the hormones decrease, almost mimicking the postpartum period, and you can actually see an emergence of symptoms upon weaning.

Alisa Minkin

Wow. And that's because, 'cause I'm thinking that the flip side is nursing can actually help mental health disorders.

Esther Rollhaus MD

That's also true, right? That's also true. And that's why the data is not, is somewhat contra controversial at this point. We don't have a clear recommendation about nursing or not nursing from a hormonal perspective, but I will say that if it's interfering with sleep, if it's causing a lot of distress. Then that is a factor in which you know, in which someone could consider not breastfeeding.

Alisa Minkin

And I've seen plenty of parents who are really struggling to nurse and then they're not sleeping and then they're anxious, and for some of them just saying it's okay.

Esther Rollhaus MD

Yeah,

Alisa Minkin

breastfeed

Esther Rollhaus MD

Yes,

Alisa Minkin

the whole mother's mental health and it helps the baby too for the mother to be,

Esther Rollhaus MD

yes,

Alisa Minkin

it's so obvious, but I feel like I need to say this. I had a mother many years ago who said to me, I will never, I will be always grateful to you for giving me permission to not nurse. And again, I'm pro breastfeeding. Okay. But the individual decision is so important. So one thing could just be lack of sleep and anxiety. 'cause breastfeeding is not going ideal. Idealistically. I wanted to take a minute to talk about something called DM a r. I didn't put it on the list, but I just thought of it.

Esther Rollhaus MD

Uhhuh

Alisa Minkin

we're having, we're doing

Esther Rollhaus MD

Sure, yeah. Dysphoric milk ejection reflex. So that's the experience when women are when in the experience of the letdown of the milk causes a tremendous distress and dysphoria. Yeah.

Alisa Minkin

What to do about that.

Esther Rollhaus MD

That's a tough one. I'm actually not a hundred percent sure, but I think that sometimes might be an indication to stop nursing. I don't know that there's actually something that, an intervention that we can make pharmacologically for DMR at this point. That being said, it might sometimes be tolerating the dysphoria, understanding that this is physiological and so some psychoeducation can be helpful for diem.

Alisa Minkin

Is it transient or is it longer lasting?

Esther Rollhaus MD

I think it depends for the individual woman. And so it's really usually when the milk is let down. So at the beginning of lactation, when the milk essentially comes out of the breast, that's generally when the dysphoria occurs, generally resolves over the feeding. But it can last for the duration of breastfeeding.

Alisa Minkin

Wow, that's unfortunate. gonna

Esther Rollhaus MD

Uhhuh.

Alisa Minkin

into that more because I don't know either.

Esther Rollhaus MD

Yeah.

Alisa Minkin

so another possibility is to not breastfeed exclusively and to do a combination of breast and, but I'm thinking of ones who, mothers don't have enough supply, Right? She's tried a lot of things,

Esther Rollhaus MD

Yeah.

Alisa Minkin

to go back to work

Esther Rollhaus MD

Uhhuh, I.

Alisa Minkin

pump.

Esther Rollhaus MD

yeah. I really find this often and sometimes in the stories of the onset of pmm, A DS happens around nursing difficulties and the mom is feeling like a failure, feeling guilty that she's not producing enough milk keeps trying everything. And really there's so much wrapped up societally in the pressure to breastfeed, unfortunately, that she feels like a failure, and sometimes that in of itself can lead to. Rumination and guilt and lead on to PMM meds, and so I really try to take the pressure off of my patients.

Alisa Minkin

We have to be very careful because we've been promoting breastfeeding so aggressively, and it's a double-edged sword. Yes, we're pro breastfeeding. Not, but I see this a lot with parents who, the mothers come outta the hospital and they have had it thrown at them. You must breastfeed. Don't give a bottle, don't give a passive, don't do this, don't do that. And then they come home and the milk's not in, and it just starts what I call the downward spiral.

Esther Rollhaus MD

Yeah, I've seen it many times. Yeah.

Alisa Minkin

So I think that feeding, planning, the feeding beforehand, not just in terms of your mental health, but even just having the mindset of, I'm gonna try, I'm gonna get as much support, but I'm gonna be okay. If it doesn't work, I

Esther Rollhaus MD

Yeah.

Alisa Minkin

not be my being a failure.

Esther Rollhaus MD

Very much and coming into that, and that's part of the postpartum planning is that these are plans, but these are not cemented. You have to take into account the actual reality on the ground.

Alisa Minkin

It's absolutely true. we could go on all day, but I know you have to go back to work and I wanna let you go, but we're gonna link to a library.

Esther Rollhaus MD

Yes. There's so many resources out there. I just wanna say people are not alone and it is not your fault. It's not your fault, it's a real thing. It's really biological. This is, nobody is to blame for peds and there's lots of help out there.

Alisa Minkin

Absolutely. And there's also a wide range of what's normal that no one has told you about, but we just did.

Esther Rollhaus MD

Yes, that's right. Exactly. It can be a really difficult and distressing time, even when we're not talking about on a level of disorder. And so both are true.

Alisa Minkin

We do not expect you to joy every minute that should be taken out of the vernacular.

Esther Rollhaus MD

And fall in love with your baby right away. No.

Alisa Minkin

All normal. All normal. Thank

Esther Rollhaus MD

I think

Alisa Minkin

much for doing this with me.

Esther Rollhaus MD

my absolute pleasure. Thank you so much for bringing this really important conversation to light. Really appreciate it.

Thank you for listening to Kids Matter. Raising Healthy, happy Children Takes a village, and I'm grateful you are part of ours. If today's conversation resonated with you, please share this episode with another parent, grandparent, teacher, or anyone who cares about kids. Together we can build a supportive community our children deserve. I'd love to hear from you. Share your thoughts, questions, or suggestions for future topics at Kids Matter podcast@gmail.com. With no explanation for your voice truly matters. Until next time, keep advocating for the children in your life because kids really do matter. They are our future. I'm Dr. Elisa Minkin and this has been Kids Matter. Please note that while I am a pediatrician, I am not your child's ped. This podcast is for informational purposes only and does not constitute medical. For any medical concerns or decisions. Reach out to your child's healthcare professional.