"She would never hurt her baby!" Post Partum Psychosis with Dr. Theresa Costales

This week I am absolutely over the moon to be joined by Dr. Theresa Costales, Arizona Medical Director for Connections Health Solutions, as we are talking all things to do with postpartum mental health but especially postpartum psychosis.

From the transient 'baby blues' to the gripping challenges of postpartum depression and the alarming reality of postpartum psychosis, Dr Costales offers an empathetic exploration of conditions that can profoundly affect new mothers.

We hear a lot about postpartum depression, and even post-partum anxiety but post-partum psychosis is massively under discussed and, as a consequence, not very well understood by many outside the postpartum mental health profession.

The harsh judgment often faced by recovering mothers, and the public's reluctance to understand that these are treatable mental illnesses, can lead to some of those who need urgent care being deprived of just that.
By examining the systemic issues within the medical community—including the dismissal of women's health concerns and the unique challenges faced by healthcare workers—we open up a dialogue about the urgent need for change and the promising shifts toward greater empathy and inclusivity, particularly for women of color.

Lastly, we celebrate the positive strides being made towards accessible mental health care for women, highlighting the ground-breaking work of Connections Health Solutions.

The importance of protocols that maintain the precious mother-child relationship during hospitalization, and the critical role of medication knowledge for pregnant and breastfeeding women, are topics we passionately delve into.

I don't say this every week, in fact I don't think I've ever said it at all, but this episode is a must-listen. Dr Costales is an amazing speaker on this subject and you'll absolutely love it.

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Playing us out this week 

Transcript

Peter Lap: 0:00

Hey, welcome to the Healthy Post Natal Body Podcast with your post-natal expert, Peter Lap. That, as always, will be me. This is a podcast for the 17th of March 2023. And, you know, day before music means I have a guest on. But boy, oh boy, oh boy, what a guest I have. I'm talking postpartum psychosis with Dr Theresa Costales. She is the Arizona Medical Director for a company called Connections Health Solutions and she is amazing. Basically they're like a mental health crisis care center and she is like insanely good. This is one of my no kidding, one of my favorite conversations I've had with one of the most knowledgeable people I've had. But basically, postpartum psychosis you'll have come across it in the news a little bit recently. They're definitely advertising it in the UK a little bit as or it's on billboards in the UK, something to look out for and it's a subject that is not really discussed all that much. So Theresa very kindly came on and without further ado, here we go. What is postpartum psychosis and what's the difference between, like, postpartum depression and anxiety and postpartum psychosis?

Dr Theresa Costales: 1:33

So that is the perfect question to start with, because oftentimes when you hear people talking about these postpartum psychiatric conditions, people will call it postpartum, and to a psychiatrist or anyone else working in mental health, that doesn't mean much of anything. It's not Everybody's postpartum After they give birth. Right, that's the state, that's how it works. So there's a couple of different mood, anxiety and psychotic disorders that can occur in the postpartum period specifically. Most commonly, what women will experience is what we call the baby blues. So baby blues is super, super common. It usually starts within a couple of days of giving birth, lasts for maybe a week, maybe two weeks, but it ends and that's a lot of crying, some low mood, maybe mood fluctuations. Anxiety can accompany that and it can be somewhat functionally impairing while you're experiencing it, but it's going to end in

Dr Theresa Costales: 2:56

an hour. So then you have postpartum depression, which is similar to the baby blues, but it's more intense. I would say the symptoms are more intense, it's more impairing and it lasts for a longer time. And typically with baby blues you're not intervening in the form of a lot of treatment, like starting a medication, whereas when we're experiencing postpartum depression those symptoms are going on for longer, it's more impairing and it can result in something like suicidality, so starting to experience suicidal thoughts and those.

Dr Theresa Costales: 3:44

That has to be treated. That has to be recognized in a timely fashion and the person has to be engaged and you have to treat that. And it can be very, very impairing for women and oftentimes it's women who have not had any prior history of depression. But in the postpartum period, with all of those mood fluctuations, it just is a ripe setup for experiencing a depressive episode like that. And I should also say that sometimes the symptoms can start occurring towards the tail end of the pregnancy. So it's called postpartum depression. It's often postpartum, but sometimes it starts during pregnancy. I think that's important to recognize. Postpartum psychosis is a totally different entity.

Dr Theresa Costales: 4:38

So a lot of times people say ask me, is postpartum psychosis like a more severe form?

Dr Theresa Costales: 4:46

of postpartum depression. If it's untreated, this postpartum depression turned into postpartum psychosis, and I would say no. So they're separate. They're separate entities. So postpartum psychosis is more rare than postpartum depression, but it is quite scary. So typically with postpartum depression you will have symptoms starting to develop, usually within the first week after delivery, sometimes a little bit longer after that, but the onset of the symptoms is quite abrupt and the presentation is quite severe. So women will start to experience a lot of confusion, almost look like they're in a bit of a delirious, confused, fugue state. Women can start to experience hallucinations, meaning they are maybe hearing voices when there's nobody in the room. Sometimes there's visual hallucinations they're seeing something that's not actually there, but more often it's auditory they're hearing voices.

Dr Theresa Costales: 5:58

Delusions meaning you've lost touch with reality. You start to believe something that is not true and there's nothing that can convince you that it's not true. And oftentimes those delusions involve something about that, involve the baby. And then there's a lot of emotional distress and what we call affective liability, where your mood is going up and down and sometimes not really in response to anything in particular. We're just having really severe, intense mood fluctuations and some kind of bizarre behaviors you can start to see from women, and oftentimes it's occurring in a woman with no psychiatric history, so it can come on out of nowhere. Oftentimes, when you look back, there's maybe a family history or maybe something that hinted at. Perhaps there could be an underlying bipolar disorder, but nothing has manifested until you have this massive hormone fluctuation happening after you give birth, combined with the sleeplessness that comes along with caring for a newborn and that stress of being wholly responsible for this tiny human and keeping it alive. And oftentimes it's when you've never cared for a newborn before, so it's a totally new experience. So all of those stressors combine for women who have this underlying predisposition to developing postpartum psychosis and can result in this very severe clinical entity.

Dr Theresa Costales: 7:42

That is what we would consider a psychiatric emergency. And the reason that we consider it a psychiatric emergency is that there is often dangerousness to the baby and to the mother's life, and perhaps to other children who are around as well, because the delusions very often involve the baby and it's often like a desire to protect the baby. So you'll hear women say that they are starting to believe that there's something demonic or evil that is after the baby and the only way to save the baby is to kill the baby and it doesn't make sense when you say it out loud like that, but it makes sense to her at the time because she's in a state of psychosis. So it's a medical emergency because you have to get the baby safe and get mom safe and get her treatment and it's a very, very treatable condition. And it's when it's postpartum psychosis.

Dr Theresa Costales: 8:55

She has not been psychotic prior to that. It's not going to last forever. You can treat it and the episode will end. But while you do that you have to get her and the baby into a safe place to do it. So there we go, thank you. In order of, I guess, severity maybe, and in terms of prevalence it would go baby blues super common. Postpartum depression not as common, but still fairly common, and then postpartum psychosis, which is more rare, but the cases really come to attention when it does occur because it's a very severe presentation.

Peter Lap: 9:48

Yeah, there's a lot in there. There's a lot, so is there. The first question someone will likely ask if something like that happens is is there a genetic predisposition to it, or does it kind of we can kind of see coming, or is this one of those it kind of falls out of the sky type things, so it's definitely both.

Dr Theresa Costales: 10:17

So there's going to be a genetic component. Sometimes you will see a history of postpartum psychosis or a bipolar disorder in a first degree relative. And oftentimes, in those women especially, postpartum psychosis is merely the first presentation of bipolar disorder. So when I see a woman who has postpartum psychosis I'm going to say I'm assuming that this is bipolar disorder until proven otherwise.

Dr Theresa Costales: 10:48

And that's how you'll treat it. So there and there's definitely underlying genetic predisposition for bipolar disorder and so that's going to put a woman at increased risk of developing postpartum psychosis. A prior history personally of postpartum psychosis is probably the most predictive. Who's going to develop postpartum psychosis subsequently. In those cases you can probably see it coming right. Like that's more predictable. But otherwise, if there's been no personal history of it, it can kind of come out of nowhere.

Peter Lap: 11:28

And so it is mainly am I right to say it's just triggered by the hormone fluctuations and the stresses of everything. It's like triggered by the overwhelm of the situation and by already being off balance, so to speak, physically.

Dr Theresa Costales: 11:45

Yes, I think there's this confluence of factors in the postpartum period and when there is that underlying genetic predisposition present and you just have that right mix of things occurring. Exactly right, you got it.

Peter Lap: 12:00

And is that then? It's like it's interesting because obviously you mentioned that postpartum depression kind of you can have the onset towards the end of the pregnancy, quite right. You point that out, by the way, because it is massively missed quite often. Yes, it is the same with postpartum psychosis that you can. I mean I don't want to use the wrong thing that you can almost see things going off the rails a little bit.

Dr Theresa Costales: 12:25

So most commonly it's happening after. I have seen it start to occur at the tail end of pregnancy yes, I have seen that and then it gets much more severe following. So that's anecdotal experience. Yes, absolutely, I have seen postpartum psychosis start in the third trimester.

Peter Lap: 12:49

And is that then? Have you seen it because you know what you're looking out for or because that's your job?

Peter Lap: 12:55

So you kind of already see this because a lot of this stuff sounds like there's a genetic predisposition, there's family history and all the sort of stuff. But it's almost like that we found out the family history after we had seen the postpartum psychosis, after the client of the patient the client I think you call most people clients came in and then we found that actually there's a family history there of like I don't know, granddad who had issues, or grandma had issues that no one in the family talked about, because we didn't talk about mental health issues.

Dr Theresa Costales: 13:33

30, 40 years ago, right, or it wasn't diagnosed properly and they just kind of, you know, did their best to chug through life.

Peter Lap: 13:41

Yes, yes, exactly. Yeah, everybody just knows about that five month period where grandma went wonky and all. But you know that's pretty much, you know we'll say to him and therefore, therefore, it's really difficult to for a lay person, so to speak, to say okay, there might be an issue here, because the run up to labor, the run up to giving birth, is messy enough, as it is right, it's quite messy.

Dr Theresa Costales: 14:13

Yeah.

Peter Lap: 14:15

I mean, there's a little stress there already. The hormones are already over the place, and you know so. Therefore, it's very easy to maybe miss those signs that you, as a professional, would spot. But a lay person just goes yeah, she's just nervous about the.

Dr Theresa Costales: 14:30

Yes, yes, and there it's. It's quite jarring to watch somebody lose touch with reality, especially somebody that you love, and I think that there is a tendency, just as a human being, to talk yourself out of there being anything more serious happening, because it's scary. It's almost too scary to face that this could be a possibility. You don't want to believe that that's true, so you write things off right, and that's normal. Clinicians do it too. Oh, of course, all the time. All the time minimize, it's going to be fine.

Peter Lap: 15:16

Yeah, I'm just going to watch the baby get to you.

Dr Theresa Costales: 15:19

You're stressed, you're not sleeping and, having having given birth twice myself, I will. I will tell you yes, I was probably a bit of a train wreck. Yeah, of course.

Peter Lap: 15:34

I don't know anybody who wasn't.

Dr Theresa Costales: 15:35

Yeah, still functioning, still going to work. I was still seeing patients, but I would sometimes fall apart a little bit at the at the end of the day You're just so tired, you know, my back hurts. I couldn't get comfortable at night, so I wasn't sleeping, and I think when you start to see people losing touch with reality, it is very important for all of us to kind of arm ourselves with this information so that you can not ignore it.

Dr Theresa Costales: 16:14

Maybe not make a huge deal out of it at first, but just pay attention and look into it and maybe ask some more questions. Reach out for help from somebody who might know more and say I have this concern Because I think when we look in hindsight they're like oh yeah, yeah, this was starting to happen, yeah.

Peter Lap: 16:41

Because I mean, I've only really come across both part of psychosis and that type of stuff from like law and order type programs and Netflix documentaries.

Dr Theresa Costales: 16:54

Yeah, netflix documentaries, the tragedies that happen that are then in the news, and these things are preventable. It's preventable getting to that point. As long as we can spot it and get the person into treatment, we can stop those tragedies from happening.

Peter Lap: 17:22

Because, like I said, it's not. Like you already said, it is not common and I have never other than reading newspaper articles when things go wrong. Right, because it's always when things are wrong, it's when it hits the news, and the amount of times it hits the news and people don't believe. Right, because that is huge right.

Peter Lap: 17:47

I mean because every single. I'll go back to law and order, because everybody's familiar with the program. I'm not aging myself too much by using that as a reference, because it's still going, still going and indeed. So, yes, exactly, and the so based on what I just that's being said about the president's. They never believe it's always eventually jury might quit, something like that. The press still goes, yeah, but for she really right, is she now using this as an excuse?

Peter Lap: 18:15

Yes, it sounds almost like I mean, for want of a better phrase we're almost conditioned to believe it's not a real thing.

Dr Theresa Costales: 18:23

Yeah, yeah, absolutely, and I think there is that tendency anytime there is a psychiatric defense. There are definitely times, as a true crime junkie myself, I can tell you there are definitely times that an insanity plea is being used as a Hail Mary and is not real. Sure, absolutely. But when I hear, as a psychiatrist who works in crisis for a living and treats serious mental illness for a living, when I hear that a woman has been arrested for murdering her baby, my first thought is was she psychotic at the time? So, because infanticide is there are situations in which there has been like longstanding patterns of abuse or perhaps there has been a lot of substance abuse and maybe the baby comes into contact somehow with substances and overdoses and dies that way. There's all sorts of tales and stories about longstanding physical abuse, violence in the home. Oftentimes you'll hear about that being more from a partner, especially if that partner is not the biological parent of the child, and that being the cause of the child's death.

Dr Theresa Costales: 20:00

But when I hear that there are pretty quickly after giving birth and that there's not that history, the first thing I think is was this postpartum psychosis, especially if there were other children who were also killed at the same time as the baby and people are saying she was a loving mother, she was like we did not see this coming.

Dr Theresa Costales: 20:35

Particularly when you see women who've had a lot of children in a short period of time, so when you have multiple children in diapers at the same time, that's actually one thing that could further put you at risk for developing postpartum psychosis. When you have that underlying predisposition, when you have that really short period of time between births, you hear in some cases that it was like you had a little bit, maybe a mild episode, after the first baby and then it got more severe with each one. And I think when you look at someone like Andrea Yates, that's a pretty good history for that sort of situation developing where she had had postpartum psychosis but it had gotten more intense, more severe each time and then finally culminated in her murdering. It was all five, I think, of her children and they were all very young. So I think a lot of times people don't want to believe that psychosis can make you do those things.

Peter Lap: 21:49

There's also some misogyny kind of woven in all of this, there are always those parts of stuff.

Dr Theresa Costales: 21:58

Yes, yes, and woven into the fabric of our society in general. But there is this desire to blame, and people are angry because a baby is dead, or maybe sometimes multiple children are dead, and when they want their anger to go somewhere, and so the easiest target is the mother, the person who committed the act, and people will not even be able to hear that she was suffering from a psychiatric disorder. And we all get out our pitchforks.

Peter Lap: 22:43

Yeah, because it is very much like that. It sounds like one of those things that, at least when I see these things, it sounds like one of those. But I had the baby blues, or we're all a little bit upset after giving birth and we don't kill our kids or we don't hurt our children. That is very much in the. You can say that about a lot of things in life, right, but we tend to right. We always tend to well, I suffered from this and I didn't go out. Or I grew up poor and I'm a billionaire and those guys. Then we all roll our eyes and go yeah, that is not what. You're the exception rather than the rule, and it's really difficult sometimes for people to accept that they could be the exception. Yeah, because it's bad enough to accept it for your neighbor or for a friend or from someone in the distance, but you yourself could potentially be the exception, and that's a difficult one.

Dr Theresa Costales: 23:49

Yes, it's almost too scary, I think, to accept for a lot of people that that could be you, that you could be a loving parent who does not, who's not violent, has no history of violence, would never even spank their child, that you, as that person, could get so psychiatrically ill very suddenly that you could completely lose touch with reality and end up killing your child.

Dr Theresa Costales: 24:20

It's too much for a lot of people to accept and I understand that. I understand that. I just think we have to talk about this just like we are now, so that we can all better understand our own internal biases and these barriers that we have to understanding and that's the only way that we're going to ensure that women have access to high quality treatment is that people understand that this is a real problem and that these tragedies could be prevented by treatment in these cases, I think they also look at cases of when men end up killing their children and they draw some like false equivalencies between those and those situations are and, of course, every situation is different and there are always exceptions, just like you said, all exceptions, but in the majority of those cases when men are killing their children, it's like a family annihilation due to, like a. You know the female partner has finally left or is in the process of leaving, and the ego can't.

Peter Lap: 25:42

If I can't have them, you can't have them.

Dr Theresa Costales: 25:44

Exactly yeah, which is a very different thing. That's not a treatable mental illness.

Peter Lap: 25:50

That's just an asshole, yeah.

Dr Theresa Costales: 25:52

Right, yeah, and it's like you have a bad personality, exactly yeah.

Dr Theresa Costales: 25:57

You're a lignant person and there's nothing I can do to treat you, but you should be kept away from society so that society can be safe for you. Women with postpartum psychosis when they get treatment, when they get the right treatment, they will go back to themselves. They will go back to who they were before that happened and the pain that these women suffer when they actually have done something to harm or kill their children and then they recover. They live with that for the rest of their lives. They wake up every morning and realize that their kids are not here because they killed them and it was not their fault at the time. It was, you know. I often say that mental illness, like psychosis, will, you know, walk with your legs and talk with your mouth, but it's not you. The mental illness has has hijacked your functioning for for a time, but it still was their body and sometimes they still have memories of having done that and they suffer until their last breath.

Peter Lap: 27:08

Yeah, because it's like you said, it's a really tricky one because people can't imagine they themselves do anything to that point, because nobody expects themselves to get ill, right, that's already the case for physical illness, let alone mental illness, which is a whole other ballgame. I think most women that I've come across and I've come across a lot of women in this job already can't imagine postpartum depression hitting them. Right, babies are old, as I always say, unicorns and rainbows. That's what babies are, because that's what we're talking about.

Dr Theresa Costales: 27:49

It's a blessing. It's a blessing, it's magic. You should be happy, you should be lucky.

Peter Lap: 27:55

And you know I'm doing a thing later on this year with like an hour and a half long chat with a lady who had intrusive faults after both kids and then a whole bit with the charity that helped her and all that sort of stuff. It's like part of a series and that conversation I happened to know the lady and that conversation was so remarkably difficult for her. And that's just postpartum depression. That is just somebody saying I didn't want to hurt my baby, but I also didn't want to be alive anymore. Yes, that type. So she wasn't just that, she wasn't. Yeah, so she had some intrusive faults, but not to hurt the baby. So I can't even imagine how difficult it is for somebody who goes through this, who doesn't quite get the help in time, to come out at the other end as a reasonably sane, well, human being that can live with that for a while, especially not with society's judgment being what. It is right because you can change your name, you can move cities, but you know that's not going to help anymore.

Dr Theresa Costales: 29:03

We've all got Facebook, yeah and the vitriol that you feel with recent cases. I mean, people were so angry, people are so angry and they just they want blood.

Peter Lap: 29:19

Yeah, and the interesting thing is because you mentioned that some of the things that cause it, you know, some of the things that are part of this could be hearing voices, see, and things that aren't really there. And you know, I've experienced that part myself. I used to have three jobs one, two, three and was working. I once did a 48 hour back to back to back sort of sort of thing. Terrible idea. I was much younger, I was in a lot younger. Terrible idea. I was an early 20s student. I'm invincible, I can do this. By the time I got to hour 36 I was answering questions from people to do with my old job that I wasn't even out at the time I was in. Can you do this for me? Yeah, no problem. All of my colleagues said dude, who are you even talking to? And it's time for you to go. Bitty bye, bye, right? Yeah, pretty much it. So it is. It is not even. Hallucinations are not even that difficult to get.

Dr Theresa Costales: 30:17

Just no, yeah yeah, um, I think that you talk to any any uh physician who has gone through a medical school and yeah, well, you guys also do it in seven hours, yeah.

Dr Theresa Costales: 30:30

I mean, yeah, you get, you get super tired and your brain starts, um, you know, trying to make sense of what it's, of what it's experiencing, and it's like not quite firing on all cylinders, you know. And so you hear white noise and all of a sudden, in the white noise, you start to hear like your brain is making out voices and, and that's it, is your brain's attempt to make sense of stimuli. Right, and that's what the brain does. It fills in the gaps where it can't. So if you're hearing white noise and it doesn't quite make sense, your brain tries to make it into something that makes sense to you. So it makes it into words.

Peter Lap: 31:09

Yeah, something you know?

Dr Theresa Costales: 31:10

yes, yeah, um, so it's.

Peter Lap: 31:13

It's scary to think about um the fact that your brain can do that yeah, the brain is messed up, so anybody listening to this talk to a neuroscientist it is insane how scary the brain is yeah, and it's.

Dr Theresa Costales: 31:27

It's remarkable given that all that can go wrong. How often it doesn't. I mean that that is. That is one thing that's that's truly incredible about the brain. There's it's it's so intricate those networks and and how they work together and everything that can impact their functioning. The fact that we all function, even most days, is pretty incredible oh yeah, it's astonishing, it's, it's absolutely, absolutely insane.

Peter Lap: 31:58

And it's interesting because you raise an interesting point. There are a lot of medical students go through periods where they just have to put so much time in, and I know this from the states and from the UK and therefore I'm guessing it's the same in Canada and I'm guessing it's the same in large parts of western Europe. Oh yeah, they do insane stretches of shifts.

Peter Lap: 32:19

I mean we have in the UK we're at all spate of doctors getting into car accidents and nurses getting into car accidents because, they don't know which way they were going anymore, right, um, and it's therefore quite odd, in a way, that a lot of healthcare professionals are so dismissive of women that come to them that say I'm struggling a bit here, a bit more than I would expect to be struggling yeah, yes, um, I.

Dr Theresa Costales: 32:51

so I think with that, it's the same tendency that we have to be like it's fine, she's. By the time, typically by the time, a woman comes to you and says I'm struggling, she's been struggling for a while.

Peter Lap: 33:10

Yeah, it's never been the first five minutes yeah.

Dr Theresa Costales: 33:14

No, no, because women are pretty resilient, right, and we tolerate a lot and we have all those same things going on in our heads, right, like I'm supposed to be happy. This is just hard. I have this beautiful baby and I'm supposed to be able to do this. So you keep quiet and you white-knuckle it for a while. So by the time a woman is coming to you and saying I'm not doing well, believe her and ask more questions because she's not. It's a lot to have to deal with.

Dr Theresa Costales: 33:56

So physicians in general I'm talking about my non-psychiatrist colleagues yeah, of course they are generally compassionate good people there's always your doctor, deaths and everything but generally compassionate good people, people who are not psychiatrists even really brilliant physicians very much struggle to understand psychiatric illness.

Dr Theresa Costales: 34:25

I have seen time and time again that they just they can't wrap their heads around it, and that also causes a lot of things to be dismissed because like, well, I just don't, I don't understand that. And so sometimes it then becomes well, it's not real, I don't get it, I can't wrap my head around it, so it's not real, and that leads to more dismissals. And then you have the general problem throughout medicine of minimizing or just kind of putting aside women's complaints because it's heard as just complaining and we do. Women do tolerate a lot like a lot and a lot of pain and a lot of stress and generally don't complain until there's something really, really wrong. And I think we have a long way to go. The conversations are happening. The education and medical school and residency are around this bias towards women, especially women of color. Yeah, these conversations are happening. There's medical education about it. I have faith and hope that it's going to turn around, but we have a long way to go still.

Peter Lap: 35:52

Yeah, and especially you know it's I don't know about where you are with regards to what most GPs, because that's usually the first point of contact, it's like the local doctor, the local GP, most GPs in my area there are now more GPs in my area, at least in our female, and I've trained a lot of them a lot of them are mothers and a lot of them kind of because it's like in the UK, it's like I'm going to get emails about this, but I quote the perfect job for mothers, right, because it's one of those jobs that you can often do part-time, so you can often do three days a week and then they go.

Peter Lap: 36:33

And I'm going to get emails telling them. I'm a jackass for saying that, because I'm going to get medical school.

Dr Theresa Costales: 36:36

I'm going to get emails, it's okay.

Peter Lap: 36:38

Yeah, but what I mean is it's one of those jobs that a lot of women are now moving into that used to be run by God knows. It looks suspiciously like me, but with hair, so basically just middle-aged white guys and there used to be, and you show up with your yucky woman bits and your yucky woman problems with babies and all that sort of stuff, and therefore it's very much. Women are complicated and it's probably hormonal, right.

Peter Lap: 37:08

Yeah, if it's not the menopause and it's baby blues or it's a time of the month and all that sort of stuff, and hopefully that we've moved away from that a little bit at least and we can indeed get a bit more understanding now that we have more women in the field that have experienced at least some semblance of the same thing.

Dr Theresa Costales: 37:32

Yeah, yeah, and I think anytime we have we're with a clinician or physician who looks more like us, the odds are we're going to, at the very least, feel more understood but there is going to be an ability to connect and have empathy. And I also don't want to say that all male doctors, all older male doctors, I know some like wonderfully empathic, just incredible human being. Sure Male doctors. And I also know I met female doctors who it's like are you a woman?

Dr Theresa Costales: 38:22

You seem to have no empathy for anything I'm going through, or you're not hearing me very well, so it's a tendency, right?

Peter Lap: 38:32

Yeah, we're talking in general terms.

Dr Theresa Costales: 38:37

But absolutely, I think you're so right that having more female physicians in these positions frontline, encountering the patients first can only be a positive for women experiencing any sort of postpartum condition at all or anything related to their hormones, to their messy lady bits, anything that comes along with them. It's going to be better for us with more women in the field and we have a lot of. As I'm thinking about it, I'm thinking about my staff here, especially my provider staff at where I work in Connections Health Solutions. So we run psychiatric crisis centers. That's a big thing, right. So I'm in Arizona and we have a facility in Phoenix and a facility in Tucson and we have a lot of incredible female providers who are encountering especially these women coming in in crisis after having given birth, and we've done a lot of education so that we are the type of place that can welcome somebody coming in and try to help them make sense of what's happening and help their family make sense of what's happening and also be very respectful of all of the disruption that will be caused, as being caused in their lives and in the bonding with the baby, the upheaval that will happen with the family when a new mom is being hospitalized and can't be near her baby. That is a lot, and it's a lot for the whole family.

Dr Theresa Costales: 40:33

And I think that we have a lot of staff who are women, are mothers themselves and understand the gravity of that situation. You don't willy-nilly separate a mother and her newborn. It has to be done when necessary and in the most humane and compassionate way possible. So we have whole protocols over making sure that women can pump if they want to continue breastfeeding or if they don't, then helping them stop milk production, of ensuring that everybody understands medications that should and shouldn't be used in women who are pregnant and breastfeeding, and making sure everybody arms themselves with that information. So we take good care to ensure that we're taking care of these women when they come in. And yeah, so it's funny that you brought that up and I just started thinking about how many women we have on staff and I think that that's been huge for us.

Peter Lap: 41:41

Yeah, I think so, and it's one of the things because obviously I had a look at your website and all that sort of stuff and I thought it was interesting, because the idea of walk-ins makes complete sense, right, because it's easy to say I'll pick up the phone to your healthcare provider and make an appointment for a day or two later and all that sort of stuff. But when you're in that moment where you, or when your family member, whoever founds I don't know who mainly gets in touch with you, but if it's, if you are in the moment of not feeling well and you feel things are going off the rail a little bit or massively so, even to then pick up the phone and wait two days for an appointment, it's just that sounds insane to me.

Dr Theresa Costales: 42:25

And two days. I mean it's huge. Oh yeah, so much can happen in those two days and that's usually the best case scenario. So in the US if you're looking for like a mental health appointment, especially a new intake, you're often going to be put on a waiting list that is weeks, usually more like months long.

Peter Lap: 42:50

That's right. This in the UK is wrong.

Dr Theresa Costales: 42:52

There's. Not having that immediate access is one thing that can have real tragic consequences, and so a lot of women in those situations will then end up going either without care or they'll go into an emergency room. And so emergency room is set up to treat medical emergencies, and some of them have developed models where they have psychiatrists and they have whole care teams there embedded into the emergency room or have like a psychiatric portion of the emergency room, but they're not truly set up to provide care and treatment for somebody undergoing this type of course. Yeah, yeah. So our model that we developed here in Arizona is is an incredible resource. So 24 seven, we never shut our doors at all.

Peter Lap: 43:49

But you can make some good sense.

Dr Theresa Costales: 43:51

We never shut our doors. We never stopped operating. We kept taking patients in the whole time. We have to be available for the community when they when they need us most, and we have. We have a psychiatric urgent care, which is something I've never before.

Dr Theresa Costales: 44:10

Coming to work here at Connections, I had never seen a psychiatric urgent care that you can just walk in when it's open seven days a week, right, and anything that happens overnight. We still have our observation unit that's open, runs sort of similarly to a psychiatric emergency room, and if patients can come in voluntarily, or if they are, and because often women who are suffering from postpartum psychosis, psychosis in general, you lose the insight. You don't have insight that you're suffering, that you need, that you need help, and so there has to be like an involuntary component of the treatment, which is also really, really hard, especially for families. But we walk you through it. So if a family member was going to come in here and say I think this is happening to my, to my spouse, to my sister, to my daughter, to my mother, we will walk you through every step of the way how to fill out the paperwork and then, and then work with the police to get that person in quickly and safely. So what we do is not in most communities. It needs to be.

Peter Lap: 45:21

Yeah, it sounds like the sort of thing that should be everywhere and, admittedly, admittedly, I haven't Googled yet to see whether there is one in Edinburgh Somehow. I doubt it. Do you know what I mean? That's because the UK is, from a UK perspective, ahead of America with regards to certain facilities. With regards to OK, we don't pay 50 grand for for any sort of bypass operation and all that sort of stuff.

Peter Lap: 45:49

But with regards to this sort of specific facility, I think we can, we can, we can learn something from, from the states, because you have some amazing facilities that do have this Because I thought about it and then thought how can we make this work for the women in a way that makes sense, rather than it being part of a generic, like you said, any accident, emergency, broken leg, broken leg, knife to the gut oh, by the way, I want to kill my kid. You can't have that conversation in that, in that setting.

Peter Lap: 46:25

No no, and it's, it's, it's magnificent. Ok, so, very briefly, what are some of the symptoms that people should maybe be on the look files for? Just? We'll finish on that one, because I know you're ridiculously busy. And just so people know what to look out for.

Dr Theresa Costales: 46:44

Yeah, absolutely so, what you will tend to see and it will come on quite quickly. So this is not something that's going to be developing over weeks or months. It's it's pretty abrupt in onset. You'll start to see some more confusion in the in the fugue states, where they're a little disoriented, might not be like think there's somewhere that they're not, or very disoriented today I'm not talking like a few days off, like it's typical when you're home with a new one yeah, like they're thinking it's like years before or months before, or they are looking at you like they don't quite know who you are, so there's an element of confusion.

Dr Theresa Costales: 47:31

And then you might hear her talking to herself, so like there's evidence of those hallucinations.

Dr Theresa Costales: 47:38

Or you might see her look to the side as though she's hearing something and there's there's nothing being said In the in the room that you can hear. Or you hear her talking to back to the voices in the room and then the expression of strange thoughts, right, so she might start to express some odd beliefs. There's often this like kind of persecutory, religious, demonic kind of slant, and often involving the baby, maybe like concern about Colts, and you know beyond what really happens out there, and it's like almost like an obsession right, and she can't stay off of it and she's like looking very concerned. And then the affective liability going from. And it's all of these things in concert that you're seeing, but affective liability going from like crying to maybe very irritable or angry laughing at times, and that's more consistent with what you see with like a typical manic episode of bipolar disorder and so but it's, it's. It's really the confusion, the confusion portion and the and the delusion portion that you see, yeah, more so.

Dr Theresa Costales: 49:07

that's like a very pronounced in postpartum psychosis, and then you might hear her making reference to needing to protect the baby from something and it's not quite making sense. So a lot of times with psychosis you'll not be able to follow the thought process and you'll there's like maybe multiple kind of strands of thought happening at once and then she's kind of skipping between those thoughts and so it's not making sense in one linear line. That's called thought disorganization. So so you can't quite follow what she's saying. It's just not really making sense. So those are, those are the big things I think to really watch out for. You can. You can see the, the, the loss of touch with reality.

Peter Lap: 49:57

Yeah, and the big takeaway that I want to get out from this episode is it's treatable. If you is, it's if you just intervene early enough and soon enough and they're not ashamed that you just get help.

Dr Theresa Costales: 50:11

Absolutely. Please get help right away. The earlier you treat it, the better the outcome is going to be, the faster it's going to be over. Yeah, you kind of nip it in the bud and that's that's the same with that manic and psychotic episodes. The longer they go on, the longer it takes to recover from them. But so you get it early, you treat it and that's how you prevent bad outcomes, and then you take it from there. Some women are going to have to stay on medication. A lot of women are going to be able to come off medication. It just depends on the person. But the point is that you've maybe saved lives.

Peter Lap: 50:48

Yeah, and on that happy note, I will press stop record here, and press stop record is exactly what I did. Thanks very much to Theresa for coming on, Dr Costales for coming on. I mean, like I said, she's a beast. I mean she's an amazing, amazing guest to have on and, as you can tell, she'll also be an amazing doctor. Like I said, she's the Arizona Medical Director for Connection Health Solutions and they do behave your health crisis care and it's you know. I mean there are some of the experts in the field. Obviously, every country has their own experts, every local facility has their own experts, but the message there that she has about postpartum psychosis being treatable, it being OK, it's a big deal, but you know you can get help for it and all that sort of stuff. It's nothing to be ashamed of. It's one that I absolutely love and therefore I was so happy when she agreed to come on to the podcast.

Peter Lap: 51:49

That is it for this week. My good friend, peter at Healthy Plus, natal Bodycom. If you know another guest that is this amazing, then send me an email. If you have any questions, send an email Again. Peter at Healthy Plus, natal Bodycom. I, my friends, am going to beat you a jaw and I will be back next week, right by now. Thank you, thank you, thank you, thank you.