PMAD: Finding Peace Amid Perinatal Mood and Anxiety Disorders

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Fourth Trimester Podcast Episode 112: Finding Peace Amid Perinatal Mood and Anxiety Disorders (PMAD)

In this episode, we are talking with Ali Starling about the significant and often under-discussed topic of perinatal mood and anxiety disorders (PMAD). Ali Starling is an experienced midwife and academic from the University of California San Francisco. We talk about her passions: midwifery, mental health, and the intersection between the two. 

PMAD Resources for Caregivers

Our discussion thoroughly explores how new parents can navigate the challenging psychological landscape following childbirth. Listen to learn more about: 

  • the nature of PMADs
  • the importance of early preparation and social support
  • practical advice on both medical and non-medical treatment options
  • the many (free) resources available

“I just want to say that you’re going to be okay. There is support out there and you’re not alone if you do have one of the many psychiatric or mental health conditions and there is help out there if you need it. It will really help you get through intrapartum, which can be very stressful and joyful and scary, and it will help you get through the postpartum period as well.”
— Ali Starling CNM, PMHNP, MPH


Full Show Notes

Ali Starling on the intersection between midwifery and mental health [00:01:55 – 00:03:13]

Birth Intentions and Preparation [00:07:22 – 00:09:17]

Addressing Anxiety and Medication During Pregnancy [00:09:17 – 00:13:23]

Mental Health in the Third Trimester [00:13:23 – 00:18:45]

Prevalence and Impact of Postpartum Mental Health Issues [00:18:45 – 00:21:14]

Common Medications for PMADs and Their Effects [00:21:14 – 00:35:20]

Non-Medical Approaches and the Importance of Therapy [00:35:20 – 00:50:49]

Handling Intrusive Thoughts and Seeking Help [00:50:49 – 00:57:14]

Preparing for and Managing Physiological Changes Postpartum [00:57:14 – 01:03:20]

Resources and Final Thoughts [01:08:57 – 01:10:05]

About Ali Starling CNM, PMHNP, MPH

ali louisa starling - fourth trimester podcast - PMAD - ucsf - headshot
Ali Starling, CNM, PMHNP, MPH and Assistant Professor UCSF

Ali is an Assistant Professor in the Division of Maternal and Fetal Medicine at the University of California-San Francisco. Prior to joining academia, she practiced for many years in the Southwest, both in Chinle, AZ and Albuquerque, NM. She also worked as a midwife for Doctor’s Without Borders and north of the arctic circle, in Alaksa. Her passion for peripartum mental health began years ago when she realized the dearth of providers that feel comfortable working with patients in the realm of peripartum psychiatric mental health and also the unique partnership that midwives can offer in this space. Originally from Wisconsin, Ali finds living in the West enjoyable, most notably due to the mountains. In her spare time when not taking care of her newborn or traveling with her partner, you can find her in the mountains, trail running and backpacking.

Selected links

Connect with Ali Starling LinkedIn | UCSF

Learn more MGH Center for Women’s Mental Health | Mother to Baby Factsheets (Check if drugs are okay to use while pregnant or breastfeeding) | | National Library of Medicine | National Curriculum in Reproductive Psychiatry Training | Postpartum Support International | LactMed Database

Connect with Fourth Trimester Facebook | InstagramAbout & Contact

Episode Transcript

Download transcript (as pdf)

Sarah Trott: [00:00:05] Hi, this is Sarah Trott and welcome back to the Fourth Trimester Podcast. I’m here with my co-host Esther Gallagher and with a special guest, Ali Starling, who I will introduce in a moment. And before I do, I want to remind everyone that we have a website which is, where you can go and sign up for our newsletter, get lots of resources and free downloads, and be alerted every time we release a new episode. And please also hit, follow or subscribe wherever you listen.

Sarah Trott: [00:00:37] So Ali is here with us as a guest because we are talking about the concept of finding peace amid perinatal mood and anxiety disorders. So you might hear the acronym PMAD to describe perinatal mood and anxiety disorders. We’re going to talk about weathering that storm and finding peace. 

Sarah Trott: [00:01:08] So Ali is such a great guest for us on this topic in particular. She is the Assistant Professor in the Division of Maternal and Fetal Medicine at UCSF, which is the University of California San Francisco. So prior to joining academia, she practiced for many years in the southwest, both in Arizona and in New Mexico, and she’s also spent time working as a midwife for Doctors Without Borders. And her passion for the peripartum mental health journey began a long time ago, when she realized that there was a lack of providers that felt really comfortable working with patients in the realm of peripartum, psychiatry and mental health. And also she discovered the unique partnership that midwives can offer in this space for their clients.

Sarah Trott: [00:01:55] She is originally from Wisconsin and she loves living on the West Coast, most notably due to the mountains, so she has a newborn herself, which keeps her very busy. And when she’s not with her newborn or traveling with her partner, you can find her hiking and trail running in the mountains, which sounds very lovely indeed. So welcome to the show, Ali.

Ali Starling: [00:02:16] Thank you. Thank you very much for having me.

Sarah Trott: [00:02:18] Yes, we would love to hear an introduction in your own words.

Ali Starling: [00:02:25] Sure. Well, I think you hit most of the salient points. I’ve been a midwife for about nine years. I trained at UCSF and now I’m back in the San Francisco community. I do work at UCSF in the Division of Maternal and Fetal Medicine. And then, like you said, I started my career working for Indian Health Services in northern Arizona and Albuquerque, New Mexico. I was a sexual assault nurse for a few years and also have done stints in north of the Arctic Circle in Alaska, working also for Indian Health Services north of the Arctic Circle. So I’m passionate about midwifery and mental health and the intersection between the two. So I really love this topic and I’m happy to be here.

Sarah Trott: [00:03:13] Yeah. Welcome. And you’re also a parent yourself. And on the show, we have a tradition of talking about our own fourth trimester experiences, and we’d love to hear more from you about yours.

Ali Starling: [00:03:27] Great. Well, yeah, this topic is very true and near to my heart for many reasons. One of them being because I’m a new parent myself. I have a seven and a half month old baby, and my fourth trimester started off very unexpected and rocky. My bag of water broke when I was 32 weeks, and then I was hospitalized for a few weeks and was induced at 34 weeks. So all of a sudden, my many, many years delivering babies and being a midwife and providing prenatal and postpartum care came to a very unexpected halt and veered and just like any labor and delivery, I experienced something that I couldn’t plan for and something very unexpected. So I was hospitalized, induced at 34 weeks. My baby was in the NICU or the ICN, the, for about two weeks. So that was a very trying experience for my partner and myself.

Ali Starling: [00:04:36] And the fourth trimester is hard, joyful, challenging for everyone. And when you have a baby that is unexpectedly or even sometimes expectedly in the NICU, it makes the fourth trimester even start on an even more trying and rocky beginning because you are shuffling back and forth to the NICU or the ICN. You are away from your baby. You are not able to do skin to skin. You were not able to sleep near your baby. And most NICUs are not very maternal or parent friendly, so it makes the fourth trimester pretty challenging to start off with, but luckily things have somewhat smoothed out since then.

Sarah Trott: [00:05:34] I’m glad to hear that it has smoothed out since then, and I’m sorry that that was a challenging time.

Ali Starling: [00:05:40] Yeah. And I’ll talk about this later in the podcast. But oftentimes people who do have higher risk deliveries, higher risk births, higher risk, or maybe poorer outcomes for either the mom or the neonate are at a higher risk for having a postpartum mood and anxiety disorder PMAD or having PTSD or trauma postpartum as well. So I definitely, I think, met the criteria for some of those instances because I had a higher risk delivery and definitely had to experience things that obviously I had no intention of experiencing. But you can never plan for labor and delivery 100%. So it was a really humbling experience and one that my partner and I weathered through.

Sarah Trott: [00:06:34] Yeah, yeah, that’s a lot to go through. And you, you definitely, mentioned the word intentions, and I appreciate that. We have a birth plan template, which we call a birth intentions template. That’s a free download on our site for anyone interested. But the word intentions is really helpful, in part just because it’s useful to think through what you may or may not want to happen as an experience. But as you’re highlighting, it’s very unpredictable to a degree. Had you at 34 weeks I mean, given your line of work, I imagine you thought it through significantly, but had you put pen to paper for anything at that point.

Ali Starling: [00:07:22] Well, being a midwife and in the birthing world, delivering babies for over ten years, I never really wanted to have a birth plan or birth preferences, because I’ve seen so many scenarios, and I like to tell a lot of my patients or clients that in some ways, the best plan in labor and delivery is to not have a plan because you never know what’s going to happen. and I find that, I mean, not always, but I think it’s good to have intentions, but also be open to the fact that sometimes things don’t happen the way that you expect them to or want them to or intend them to. and because I work in a space that is higher risk, I meant a hospital as a midwife. I’ve seen a lot of different scenarios play out. and a lot of different expectations in the birthing world that haven’t been met. And I think that I started preparing for my fourth trimester when I was about 25 ish weeks, because I’ve seen so many different scenarios and people who haven’t necessarily prepared for their fourth trimester.

Ali Starling: [00:08:37] And so I really try to recommend my patients to prepare, start preparing when they’re between 20 and 30 weeks, because things can happen that you don’t expect. And I think it’s better to be a little bit prepared, whether that’s just getting a registry, preparing your apartment or house with certain supplies, getting your bottles ready, your breast pump ordered, various things like that because you really don’t know what’s going to happen. And I think being prepared for the fourth trimester earlier on the earlier side is, is my recommendation.

Sarah Trott: [00:09:17] Yeah, for sure. And sometimes the benefit of having a plan is not because it’s going to go the way you want, but sometimes just doing the research and learning and given your line of work, you’re a professional in the space. So you really understand the language and the words and the possibilities at a very deep level. But for people who are not in this space, sometimes the benefit is really just understanding what could happen, learning some of the language, learning what the options are so that they’re informed, at least going into it, but having the mindset of preparing early. I love that and love the whole point about it’s not necessarily going to go the way you want. Your experience is an example. But another thing you did, you prepared in advance. I think you mentioned something when we were doing our prep about medication that you thought through.

Ali Starling: [00:10:16] So one reason, one of the many reasons that I enjoy this topic is because I myself have a diagnosis of an anxiety disorder which is  pretty common in my age group and in the postpartum period as well. But one thing that I did was I went up on my medication when I neared the third trimester. And that is oftentimes the recommendation that we give certain people who take certain medications in labor and delivery and, and prenatally as well, just because there’s so many physiological changes that happen when you’re pregnant.

Ali Starling: [00:10:55] So when you start, especially nearing the end of the second and start of the third trimester, around 28 weeks, one of the main changes is huge plasma volume increases, so the volume of blood fluid in your body increases. Pregnant people just hold a lot more fluid. So if you think about that, your medications will become diluted in your system. So that’s why oftentimes most conditions in pregnancy, whether that’s diabetes or high blood pressure or just whatnot, we recommend to go up on the medications in the third trimester.

Ali Starling: [00:11:31] So I recall when I was nearing my third trimester, I at one point had had a mild, panic issue, and I was like, I think it’s about time to go up on my medications. And so I did, and I think it really, really helped with me for the rest of my pregnancy and my postpartum period as well. So that’s something that I did. Like I said, it’s not for everyone, but it’s usually recommended oftentimes in the psychiatric world.

Sarah Trott: [00:11:59] And some people will think that they would reduce or come off of anything. I stopped drinking caffeine as a personal choice and certain things like that. Like I was very cautious about what my body was taking in nutritionally or whatever else. and so it may be counterintuitive to hear that, but if you’re working with a professional who knows that the medication is safe for your pregnancy, and that’s the recommendation, then it sounds like the right thing to do, obviously, is to follow your advice from your medical team.

Esther Gallagher: [00:12:37] And, Ali, since we have you using yourself as your own example, can you speak to how things were able to shift for you by, by way of getting those meds and availing yourself of them?

Ali Starling: [00:13:23] So I think that what I noticed and what I think a lot of pregnant people notice, is that there are a lot of these expectations that you’re preparing for birth. Most of us are still working full time. We are living in very somewhat stressful environments, urban environments commuting to work, working long hours.

Ali Starling: [00:13:44] And I’m living in a one bedroom apartment with my partner. And we were looking at moving and looking at preparing for baby. And it just got to be too much. I was overwhelmed, woke up in the middle of the night and had some symptoms of a panic attack, which I hadn’t had for many, many years. And I realized that to me, it was not worth it to move. It wasn’t worth it to have more panic attacks. It wasn’t worth it to be anxious and stressed. And the medication that I had been on for many years at that time, my body was changing, it was becoming more dilute, and the medications were not working as well as they would have when I wasn’t pregnant and had my pre-pregnancy body. And so I noticed that by going up on my medication, it sort of brought down my threshold for stress, my threshold for anxiety. And, I mean, I didn’t have any other panic symptoms the rest of my pregnancy.

Ali Starling: [00:14:46] But, I mean, it’s different for everyone. That’s for sure. But I think that one point that I’ll make later, too, is that there’s all these societal expectations you need to, to move to a bigger apartment or move to a bigger house or buy a car that is better for baby, and you really can’t do it all. You can’t, especially when you’re working full time. So I think that preparing as much as you can, but just realizing there’s no way to get it all done.

Esther Gallagher: [00:15:18] Yeah. I also think that for a lot of us, somehow we’re expected in the third trimester to get it all together and get organized. But the thing is that so much is coming at us that getting organized can be we just become overwhelmed and therefore can’t get organized around the basics and the basics, in my opinion, and I’ve said many times on the podcast, are making sure you’re not anemic, making sure you’ve got enough good, your blood’s healthy before you go into labor and birth and breastfeeding. And we’re having prenatals that are coming at us that are very baby focused.

Esther Gallagher: [00:16:06] But it’s my experience as a long time caregiver & support giver, that women’s health in the third trimester is starting to gradually erode because no one’s telling them it’s time to slow down. It’s time to rest. It’s time to make sure you’re not anemic. It’s time to get enough sleep, and you’re only going to get it if you sleep during the day. And of course, you know Sarah knows. I know if you’re working full time, no one’s letting you take naps. You know, it’s just a nut job situation, right?

Esther Gallagher: [00:16:45] So if your mental health is even just a little bit disorganizing is a word I use. You know, it’s ordinary. Normal. Confusion, but the volume’s been turned up because of your situation and your potential, your past history with mental health. And I mean, I personally think it’s a miracle that any of us get to childbearing age and aren’t already anxiety disordered in this culture. So if meds are going to be the thing that just helps you drop down into a slightly more organized body and presence for yourself, then it’s sad to me that women strongly resist taking medication when they’re about to be crashing into the wave head on of all the things right? Late pregnancy, early motherhood. Early motherhood that isn’t complicated – I’m speaking about myself now – can be very, very anxiety provoking.

Esther Gallagher: [00:18:04] So whatever it takes to just not feel like you’re right on the edge. Every breathing moment would be a boon. yeah. So thank you. That’s why I’m thanking you for showing up here. I’ve got decades of experience with this, and you know, Motherhood doesn’t get easier in the fourth trimester. It just doesn’t. It takes a while. So going into it, under-resourced is never what we want for moms on this podcast. So thank you.

Ali Starling: [00:18:45] Yeah. And you know, I appreciated Esther how you said the third trimester is a time to slow down. I’m an ultra marathon runner, and it was very hard for me to slow down. and many of my patients have asked me about certain things that they did pre-pregnancy. And now what do they recommend? Pregnancy and things such as running, etc. and I think you should follow your heart, follow what your body says, and if it’s healthy for you and your health care professional says it’s okay, do it. And in general, your body has to sort of slow down when you’re pregnant because these hormones of pregnancy, such as progesterone, do slow your blood volume down, do slow your GI system down. And it is a really good time to prepare in the third trimester for the fourth trimester. So I appreciated you saying that.

Esther Gallagher: [00:19:43] Yeah, your baby doesn’t have time for you to be running ultramarathons in the fourth trimester. You know, if they’re going to get fed and cared for.

Ali Starling: [00:20:05] And then I wanted to say that you know, just to continue to decrease the stigma about mental health issues according to the American College of Obstetricians and Gynecologists, up to this is a pretty large range. But 5 to 40% of birthing people postpartum meet some sort of criteria for anxiety. And about 1 in 7 meet some sort of criteria for postpartum depression. And then there’s a huge overlap with over half of people who have pre-existing mental health conditions having both depression and anxiety. So a combination of both anxiety and depression in the fourth trimester or the postpartum period. So I just want to say how common fourth trimester mental health conditions are. And one of my goals is to decrease the stigma. And I just want people to talk about it. I want people to reach out for health. And I want people to know that there is help out there if you need it. And yeah, there are resources out there.

Esther Gallagher: [00:21:14] We’ve talked a lot on the podcast about non-pharmaceutical benefits, you know approaches. In fact, we just did a chat about that and we talked about mindfulness based stress reduction. We talked about somatic experiencing for PTSD or other trauma trauma bodies. And we talked about the nervous system and regulation and all those things. And we’re happy to talk about them with you again, of course. No problem. But are you willing to do a little bit of a dive into what is considered safe and pharmaceutically these days and how these work and the physiology of them?

Ali Starling: [00:22:07] Sure. And I just want to say that in general, most psychiatric mental health providers would say that for mild psychiatric disorders or even some moderate psychiatric disorders. So if you meet the criteria for whether that’s anxiety or depression or postpartum, you can treat them and you can get solace and relief with non-pharmacological means. Definitely. And so I love how you’re really focusing, and you’ve talked a lot about non-pharmacological relief because that is by and large how most people improve.

Ali Starling: [00:22:47] So if you don’t have a debilitating issue, if you’re able to function fine and you might just have mild anxiety or mild postpartum depression. You probably don’t need medication. and you probably would be fine with talk therapy or mindfulness or changing your diet or you know, other means, but it’s the when you cross that threshold and you get into the moderate to severe postpartum depression, moderate to severe postpartum anxiety and then definitely if you have a criteria for obviously postpartum psychosis or something, that’s a little bit more definitely more acute is when most research and evidence would say we definitely recommend medication at that point. So yeah, I really appreciate that. You’ve talked a lot about non-pharmacological means so yeah.

Ali Starling: [00:23:48] So medications can be really, really helpful. And they’re not helpful for everyone. And a lot of people don’t want to take medications. And that’s 100% your choice. Right. Just like Anything in life. You are in charge of your body, and it’s your choice whether or not you want to take medications. So it’s up to you and your health care practitioner to use shared decision making and your health care practitioner to really go through the risks and the benefits of every single medication that they recommend to you.

Ali Starling: [00:24:22] But I do want to say that similar, like I already mentioned, if you had if you had diabetes, your health care practitioner would probably highly recommend you to take insulin if you had high blood pressure or postpartum high blood pressure, your health care practitioner would probably definitely recommend you to take some sort of antihypertensive medication. If you had a blood clotting disorder or a DVT, especially postpartum, your health care practitioner would probably highly recommend you to take an anti clotting medication if you had and the list goes on. Right. And immune conditions. And so medication for mental health conditions is the same. Your health care there’s a reason they exist. There’s a reason that they’ve been made. And there’s a reason that we would highly recommend to take them as well. So I want to just let people know that if you do, if you are recommended to take them, it’s okay. And millions of people are on pharmacological medications for various conditions.

Sarah Trott: [00:25:31] And there’s no stigma around a blood thinner. Around some of these other medications that are so common. So why feel bad? It’s not your fault. It’s not anyone’s fault.

Ali Starling: [00:25:44] Exactly. Exactly. Or asthma. Being on an asthma medication. Right. so, yeah, I’ll just do a quick, quick and dirty talk about what are the most common medications that we recommend, by and large, for PMAD or perinatal mood and anxiety disorders. I’m sure most all of us have heard about SSRIs or serotonin selective Re-uptake inhibitors, which are not so selective, actually meaning they have various side effects. So most of the time, if people do not have a history of mania or bipolar disorder in their family or themselves, we would recommend an SSRI postpartum or prenatally if they do meet the criteria for a moderate or severe anxiety disorder or depressive disorder. The two most common are Sertraline or Zoloft or Lexapro escitalopram, which are also two of the most common medications that we prescribe in the nonpublic pregnant population as well. So these two medications, I would say, by and large, are the most common. There are side effects involved, like with every medication. You’ve all probably heard of some of the side effects. Very commonly, short term, it’s like GI issues, nausea, vomiting headaches. Long term there might be some people who say there’s weight gain. Sometimes there’s sexual issues, inability to orgasm. Everyone’s different. So there definitely are side effects. Some people say they lead to emotional blunting. Sometimes they lead to some restlessness or insomnia. So ideally, if you do meet the criteria, your healthcare practitioner will go through all of the side effects of the medications and then go through all the benefits of the medications. And so one of the reasons it’s so important to treat mental health conditions and pregnancy and postpartum are for the newborn’s health as well, and for the mom’s health or the parent’s health.

Ali Starling: [00:28:07] If you don’t get treated, the fetus or the baby is still exposed to the illness. So there’s an exposure to everything. There’s either the fetus or the newborn is exposed to the medications potentially a little bit through the breast milk or a little bit through the placenta or the fetus, or the newborn is exposed to the birthing parent being ill or the birthing parent having a postpartum condition. So there’s always an exposure.

Ali Starling: [00:28:41] So the fetus or the newborn that’s exposed to a birthing parent that has anxiety or depression, there have been studies that show there’s less ability to bond with the birthing person. there’s less rates of breastfeeding with the birthing person. There’s less rates of the newborn going to preventative care visits, less increased rates of the emergency department usage. There’s more difficulty attaching to the caregiver, increased rates of ADHD and increased rates, long terms of things like anxiety and depression and in the newborn. 

So there’s definitely many reasons to get treatment when you are a new birthing person or when you’re pregnant and when you’re pregnant, there’s increased rates of preterm birth, increased rates of low birth weight, and increased rates of high blood pressures. If you’re not treated for perinatal mood and anxiety disorders PMAD and then obviously more acute issues if you’re not treated worse. Definitely. Worst case scenario, increased rates of suicide or homicide for conditions that aren’t treated. And then increased rates of substance abuse too. So for people who aren’t treated it leads to higher rates of substance abuse. 

Esther Gallagher: [00:30:08] Can I just butt in here real quick and say, I don’t want anyone who’s listening currently to assume that we’re only ever talking about moms here. Biological women carrying fetuses. Yes. In terms of what you’re talking about, physiologically, exposures in the womb, of whoever’s womb you’re in are a real thing, right? It’s either cortisol or whatever hormones were shooting off as a result of our anxiety. But we know for a fact that it’s no small thing, that there’s a significant proportion of male bodied people who are living in the perinatal space are experiencing anxiety and depression. They act it out differently most of the time. And that’s one of the reasons why postpartum women are at extremely high risk for homicide. So if you’re a person, a male bodied person in the perinatal space and you’re experiencing distress. It’s imperative, just like for the rest of us, that you be seen and attend to your mental health. So just how to make a pit stop there?

Ali Starling: [00:31:35] No thank you, Esther. And not just for people who are male either, just anyone that has a newborn. So whether you are fostering a newborn or adopting a newborn are a non-biological parent. Definitely. Undoubtedly. So I really appreciate you bringing that up.

Ali Starling: [00:31:53] Anyway, so do you all have any questions about sort of what I was talking about with the risks and benefits of being on medications.

Esther Gallagher: [00:32:02] I’m curious when it comes to SSRIs. So many of the symptoms that you mentioned, like, taking the drug sound to me, like symptoms of having depression, right? Like one, I’m always curious, like, is that just part of the transition through the onset of the drug starting to work and then those symptoms relieve? You know, we talked about physical symptoms like nausea, eating maybe an increased appetite or just weight gain and the headaches. And so I’m curious. I have a family member who was treated with them and then became manic.

Ali Starling: [00:32:57] Yeah. No, definitely. And that’s. Yeah, that’s why I mentioned it’s important in the American College of Obstetricians and Gynecologists recommends screening everyone prenatally and postpartum for anxiety, depression and bipolar disorder because you definitely want to make sure that no one has manic signs and symptoms. Meaning if you’ve ever experienced a time in your life that you have been so wired that you haven’t needed to sleep for 4 to 7 days at a time, and done sort of reckless activities or engaged in you know, things such as like shoplifting, overspending, extreme drug use, sexual promiscuity, etc.. There’s a huge list. and, or if you have a family history of mania or bipolar disorder, you might be a little bit more cautious when you prescribe an SSRI. Undoubtedly. So thank you for bringing that point up again.

Esther Gallagher: [00:33:55] And this would also be a good reason why you want to. If you’re going to go this route, you want to really find a support system that will keep you in touch with your psychiatric team. Because if you start to go off the rails, you’re not necessarily the person who’s best equipped to apply yourself to the project of getting seen and adjusted, so to speak. 

Ali Starling: [00:34:28] One thing that I see with my patients is that there’s a stigma around certain mental health conditions, and there’s a stigma around not wanting to be on these medications for breastfeeding. And I think hopefully some of the myths surrounding psychiatric medications with breastfeeding have been increasingly debunked in our common literature and society.

Ali Starling: [00:34:52] But most medications are safe for breastfeeding. There are some rare exceptions. but it’s definitely worth it to talk with your health care provider about the psychiatric medications you’re on or any medications that you’re on, for that matter, whether it be a medication for asthma or medication for high blood pressure to ensure but you know, most are okay with breastfeeding. 

Ali Starling: [00:35:20] And I think that, you know and if they’re not, then you can make that decision with your health care team that maybe it wouldn’t it be safe to to breastfeed or pump or express your milk for your infant and do some other means of feeding?

Sarah Trott: [00:35:37] And that’s true for pregnancy as well. Is that right?

Ali Starling: [00:35:40] For medications? yeah. Yeah, definitely. And so I mentioned SSRIs, but there are many other medications that people take for anxiety, depression, OCD or obsessive compulsive disorder, panic disorder. There’s a plethora of medications out there. and most medications, if you’re on something and you’re stable in pregnancy, most of the time your healthcare provider will tell you to stay on that medication. Yes, there are exceptions. So like I said, it’s important to talk to your health care provider. And there’s not certain medications. There’s simply not that much data on them. the FDA is slow to approve and do studies. Obviously, it’s hard to do studies on pregnant people and postpartum people because it’s unethical. But just because there’s not data and studies evidence doesn’t necessarily mean that it’s unsafe. That’s similar with supplements, right? There’s a lot of supplements out there that don’t have the FDA approval for anxiety, depression, etc. but that doesn’t mean that we take them every day and that they’re not safe.

Ali Starling: [00:36:52] So it’s important to have that conversation with your healthcare provider. So, for instance, if you’re on a very common anti-depression medication called bupropion or Wellbutrin, or you’re on a common medication called duloxetine or Cymbalta, that’s just an SNRI, that doesn’t mean that just because you’re not on sertraline and or Lexapro, you can’t stay on that medication because you’ve had success with that medication. and in fact, most of the time your healthcare provider will want you to go up or recommend you to go up on that medication, like I already mentioned in the third trimester, to meet the physiological demand of the third trimester. And then that’ll probably help in the fourth trimester as well.

Ali Starling: [00:37:34] But the fourth trimester is interesting from a physiological perspective, because oftentimes your demands for medications will decrease, but that will be something that you will work with your healthcare team.

Sarah Trott: [00:37:48] And then the question that I had for you about the side effects, I mean, that can sound really off-putting, like, who wants to have that laundry list? It’s like I am just trading one set of things for another. Right. But I’m curious to know, like just because it’s a potential side effect, it doesn’t mean that that applies to everybody. Taking the drug doesn’t guarantee those side effects. Each person is different and they may or may not have those side effects. Right?

Ali Starling: [00:38:13] Yeah, 100% I mean every drug affects everyone differently. It’s like when I was in labor. When I’m working with laboring patients, there’s all these myths and fears around pitocin, which is the most common medication that we give for people in labor. People have really strong feelings about pitocin with reason. And oftentimes people are okay with it. They do fine with it.

Ali Starling: [00:38:40] Or birth control. Every person’s body reacts differently to various types of birth control. I loved my Mirena IUD. I had two different ones. It worked great for my body, but I have so many friends and colleagues that would totally swear off the IUDs, swear off Mirena IUDs because they say the hormones affect their body.

Ali Starling: [00:39:02] Everyone reacts differently to medications. And so it’s really up to you to let your health care provider know and work with them.

Ali Starling: [00:39:10] And there are medications that you can take for side effects too. So if you have dry mouth, if you or if you’re sweating a lot postpartum due to your medication – which postpartum people often sweat anyway – there are medications you can take. Or some people have had sexual side effects with certain psychiatric medications. There are medications you can take for that too. So that’s a very good point, Sarah.

Sarah Trott: [00:39:40] Thank you. Thank you for clarifying that. and so we were going to also talk about some of the non-medical approaches.

Ali Starling: [00:39:52] Yeah. so please feel free to chime in because I know that you all have talked about this a lot. but I think that, like, like I wanted to say already, I think preparation is really important preparation in the second and third trimester for labor and delivery. And the fourth trimester can help decrease your threshold for a postpartum condition. So obviously, if you’re using substances, decrease that. Working on if you have, for instance, if you’ve had trauma before, like trauma with a previous birth or a poor birth outcome, poor birth experience working with a psychologist or a mental health provider to help decrease the trauma response that you might have going into the next birth and prepare for the fourth trimester.

Ali Starling: [00:40:49] If you have a previous history of PMAD postpartum anxiety and mood disorder, help preparing with medication and or preparing your social support and your social team for the next postpartum experience to try to prevent it from happening again. I find that my patients who do have experiences in the fourth maybe not the best fourth trimester experiences, if they prepare the next time around, they usually have a better experience. So it’s really fun to watch and to see that preparation can be key for a lot of people that have a history of maybe not the best fourth trimester experience.

Ali Starling: [00:41:30] So I already mentioned therapy psychosocial therapy talk therapy. And important to really let your therapist know or your talk therapist. There are so many different types of therapy. And so not just to have a therapist who’s, like, acts as a friend, but to have a therapist that really can specialize and hone in on exactly what you need. So, yeah, if you do have a history of trauma, someone that works in eMDR or rapid eye desensitization and or exposure therapy that can really hone in to exactly what you need.

Ali Starling: [00:42:06] And social support obviously is key. In our day and age when we are very isolated, Covid notwithstanding, COVID’s hopefully going down. Although I saw headlines that maybe the rates are increasing. to have that social support in the second and third trimester and start building it. So whether that’s a meal train or whether that’s having people visit you before you give birth and have this social network before can be really helpful postpartum. If you guys want to chime in to feel free, I know that in your podcast you’ve had guests before that I’ve talked about the importance of sleep.

Ali Starling: [00:42:46] sleep is medicine just like food is medicine. If you have postpartum insomnia and third trimester insomnia is a huge issue. So working with your healthcare team there are medications you can take for sleep too. So if you are to the point in your fourth trimester journey that you cannot sleep, you can’t sleep when the baby is sleeping, you can’t, you’re only getting a few hours of sleep a night or a few hours of sleep during the 24 hour period. There are  definitely ways to improve upon that. I know we’re supposed to be talking about non-medical ways, but there are medical ways to improve your sleep as well.

Ali Starling: [00:43:31] Exercise, getting outside. vitamin D, getting sunlight is tantamount to feeling. Well, if you’re living in an environment where you are, it’s cold weather. You might have seasonal affective disorder, getting a heat lamp or getting some sort of lamp to help give you more light can be really important. and ecotherapy, there’s been more increasing literature about the importance of getting out in nature. Getting away from the concrete jungle. Jungle can be very important. 

Esther Gallagher: [00:44:04] We did a podcast while back with Reise Tanner, who, does these wonderful moms groups called Wild Return. And it’s all about getting together with babes and getting out in nature and talking it out and all the things. 

Ali Starling: [00:44:27] No, that’s so important. And it’s, I mean, it’s hard in an urban environment too. And many of us with a newborn don’t want to drive or don’t have somebody that can drive us. And you’re home alone. And just getting out into your urban environment can be scary sometimes. 

Esther Gallagher: [00:44:45] I will say that one of the ways one can prepare if you already know. That you’re living in an environment that you’ve found intimidating, shall we say? learning the public transportation system so that you are not isolated. Just learn it, practice it a couple of times, go into places that are going to help you feel fine. You know, in San Francisco, all plenty of buses get you within spitting distance of Golden Gate Park. So as an example, right. Learning these things people who are reliant on car culture that don’t have cars. It’s a mental health game to shift your perspective on that and not feel isolated. And if you do live in a concrete jungle, you probably also live where there might be public transportation of some sort. So, um.

Ali Starling: [00:45:49] Yeah, it’s a great point. all about preparation. and then one thing that I wanted to chime in there is that we do spend a lot of time on our phones. This is you can probably look in every major news media outlet about how we’re spending too much time on social media. And so I chose when I was pregnant to for my New Year’s resolution, I believe I chose to to get rid of social media. It brought more joy to my life. I’m not saying it’s going to bring joy to everyone’s life by getting off of social media, but there have been increasing studies that show that we do spend too much time on our phones and do spend too much time scrolling through Instagram and TikTok, etc.. So that’s a suggestion that some people find helpful. 

Esther Gallagher: [00:46:41] I’ll piggyback on that one and say you could stop watching the news and nothing bad would happen. You could just stop because there’s nothing you’re doing about it. You’re riling up your nervous system, and in some cases, people are doing it from the time they get up until the time they go to bed. And it’s mostly all bad. And then you’re carrying that around, not doing anything about it except systematizing it. So I always think it’s a really smart idea to not wait until you can afford a yoga retreat, but to just take a break from it. Just take that fast. Yeah, fast from the news. You don’t have to know all that stuff. Yeah, and nothing bad will happen. Only good things will happen if you stop listening to the news, I promise.

Ali Starling: [00:47:40] Yeah, that’s that’s great. And you know, you mentioned mindfulness before and just how sometimes in our fast paced culture we don’t take time just to sit. And when we’re breastfeeding or however we’re feeding our newborns, just looking at their eyes instead of looking at our phone. I had to triple feed for two and a half months, which means I got an hour of sleep chunks for about three months, almost. and it was so hard not to scroll on my phone when I was doing that. But I think your newborn will feel more attached and the bonding connection will be better. You will produce natural oxytocin more if you aren’t looking on your phone in the news and actually looking at your baby and bonding with your baby and less cortisol.

Esther Gallagher: [00:48:30] Right? Yeah. News, news is cortisol. Babies are oxytocin. Take your pick. Cortisol doesn’t do anything good for you. Unless there’s a tiger in the room. Right? Then. Then it might be helpful.

Ali Starling: [00:48:45] Yeah, yeah. Well, and I like to tell. I like to tell new, new parents and even prenatal patients that some cortisol can be a good thing. so some anxiety is a good thing. So if we didn’t have any anxiety, we’d be sitting on the couch watching TV all day, not working and not caring. so I think some anxiety can get us to be proactive. Some anxiety can get us to care. it’s normal to be anxious as a new parent. It’s normal to be worried about your new baby or about your new family. But when you reach that threshold where you’re worrying is coming to become nonfunctional, and when you’re worrying is to the point where you can’t take care of yourself and you can’t take care of your baby, that’s when you you really need to seek help, medication and definitely non-pharmaceutical or non-medicated ways. But medication as well can be extremely helpful.

Sarah Trott: [00:49:48] I’ve heard people refer to some of that as interruptive thoughts. Intrusive thoughts right where you’re you’re you can’t stop thinking about the anxiety. You’re trying to focus on something else, but it keeps popping up. Does that ring true? Is that like a good signal to reach out for help?

Ali Starling: [00:50:06] Yeah, intrusive thoughts can definitely be a sign of like, fourth trimester postpartum OCD, for instance, or anxiety and like rumination. So thoughts that are just like circling you know, asking  my patients before people who are afraid that their baby isn’t breathing. And so every five minutes they’re having to check to make sure that their baby is breathing or being afraid that they’re going to drop their baby, or being afraid that they’re not taking care of their baby. Well, yeah, definitely. Sarah these thoughts that you feel like you’re out of control, these thoughts are controlling yourself. That can definitely be a sign.

Sarah Trott: [00:50:49] I mean, I had all of those thoughts, I think, but like, it wasn’t I think the difference was like the or the distinction here is like thinking about it constantly or having it be something that’s too much of a distraction to actually live your life.

Ali Starling: [00:51:04] Exactly. Yeah. You were able to function, I assume. but sometimes if you’re if you’re crying all day, every day, or just feeling not experiencing any joy with your newborn that that’s that’s a problem, right? Newborns are extremely hard, but they also bring joy. And if you’re not, if you’re not having any joy whatsoever and have other symptoms, that might be a key to seek help.

Esther Gallagher: [00:51:33] And I’m going to add in anger, which is the one we’ve never talked about. But if everything’s making you angry all the time and concomitantly you’re not experiencing joy. That may be the way your depression manifests. As you know, just everything seems to make you angry. You’re blaming and shaming everything around you because you just feel crap all the time, and you’ve got to find a way to kind of. Express it. And it’s not that you should never feel angry again. Cortisol. Sometimes a good thing and an angry moment is appropriate when things need to change. But if it’s just nonstop and. And especially if it’s escalating into. Abusiveness. And that’s a problem for everybody involved. Everybody involved.

Sarah Trott: [00:52:50] You mentioned eating. Was there something you were going to talk about as it relates to certain kinds of foods that might be beneficial or helpful?

Ali Starling: [00:52:57] Well, yeah, I mean, we I think in the fourth trimester period, it’s a really it’s a time to to indulge in yourself if you can and do food can bring joy, just like a newborn can bring joy. and that’s actually a sign of, of depression is if you’re don’t have an appetite. Or eating too much is an atypical sign. But finding joy and eating things and realizing that especially if you’re sitting breastfeeding and or feeding your baby for hours a day. which is your main job, it’s important to have some sort of small bouts of joy during the day. So I think it’s time to have people cook meals for you if you can, if you have the means to have people to eat what you want. It’s probably not a good time to go on a you know, certain types of diet and be worried about what you look like. so I recall when I was in the immediate postpartum experience, I would eat lactation cookies every day. I had like, well, it’s sort of still hasn’t changed, but I would have 4 or 5, like really juicy lactation cookies loaded with a bunch of great great galactagogue eggs and chocolate every day.

Ali Starling: [00:54:21] And I would have a nonalcoholic beer maybe every other day, which is also, in some cultures, considered a galactagogue. and mother’s milk tea. So eating things that bring you joy. I think it’s important in the fourth trimester. and then there’s some research and data about things such as flavonoids. I don’t know if you’ve heard of those before, but things like that are found in berries and nutrient anti-inflammatory foods in the postpartum period can be really helpful and boost up your immune system and boost up your postpartum experience. So, yeah, flavonoids, berries. occasionally, depending on if you red wine is something I don’t know if I would necessarily. very occasionally to have a glass of red wine in the fourth trimester, or definitely dark chocolate in the fourth trimester can really be helpful. Doesn’t hurt.

Sarah Trott: [00:55:21] Thank you. And so if someone is wanting to invest in some of these non-medical approaches, it’s not a either or. It’s an and. There’s talk therapy and getting social support and getting your sleep and exercise. All of these things are considered together right.

Ali Starling: [00:55:40] Yeah. And then just know that there is light at the end of the tunnel. The fourth trimester. It ends. I think I’m still in it right now, but it’ll end. Your sleep will improve. It’s something that your body will get back to its pre-pregnancy state. And if it doesn’t, that’s okay too. There’s so much joy having a newborn. There’s so much happiness and giggles and laughing and bonding and so much oxytocin flowing. But then it also is very hard. And so just to have those two mindsets is important.

Sarah Trott: [00:56:23] Yeah. Thank you. I like your point about social support too, in part just because we had Jane Honikman on our program a couple of times, and she’s one of the founders of Postpartum Support International. I remember we quoted her. I mean, she said, the number one thing parents need is to talk. And have that social connection. So whether that’s creating a parent group or finding one. And we’ve talked a lot about that on the show with Rebecca Walsh or if it’s about a listening partnership, I mean, you don’t really have to pay money for this. I know there are paid groups online, but I don’t think you have to spend any money to find someone who’s trusted, either through a parent group or an existing friend who’s trusted to be able to talk with you and listen without judgment. So valuable.

Ali Starling: [00:57:14] Yeah, totally. And yeah, I agree. I mean, there are lots of groups out there to pay for, but most hospitals, whether it’s UCSD or in the Bay area, whether it’s UCSF or Sutter or Kaiser, have groups that are already formed to that or Highland that you can join postpartum that are free. and many, yeah. So I totally agree with you. It’s really important.

Esther Gallagher: [00:57:37] Ali, this might help you a little bit. You just mentioned that you feel like you’re still in the fourth trimester a little bit. When I was doing home birth midwifery, we were having a class and somebody – we were talking about postpartum – and somebody asked, how long does the postpartum period last? And I just was like, right there with “till your kid goes to kindergarten”, like it’s all it as long as it’s all on you. Your postpartum, when somebody else starts to be able to get that kid out in the world a little bit and off of you, then it feels a lot lighter in some ways. 

So I think it might be normalizing for breastfeeders to understand that you know, your whole physiology is different. As long as you are breastfeeding in some way. And so just to understand again, it’s just a different body hormonally. which is not to say somebody who, for whatever reason, wasn’t wasn’t breast or chest feeding wouldn’t also have similar experiences if they’re 24 / seven, kind of first responder for a child. So, yeah, there’s a lot to having children under the age of going to school.

Ali Starling: [00:59:22] No, definitely. And something that for instance, I was seven months postpartum, but I got my period when I was like three months postpartum and I was like, what? This is so unfair. I’m exclusively breastfeeding now. I’m leaking fluids through all my orifices. And it’s something that we don’t talk about. I’m a midwife. And like, I realize how hard it is to manage many orifices in my body at once. they say, oh, yeah, if you exclusively breastfeeding 95% likelihood of not getting your period in six months. But I got it at like month 3 or 2 and a half.

Esther Gallagher: [01:00:02] How fair is that?

Ali Starling: [01:00:07] Anyway, just lots that is not talked about in our society with postpartum.

Esther Gallagher: [01:00:14] Yeah. I mean I feel very fortunate. Again, I say it often enough on the podcast that my perinatal care from start to finish was home birth midwifery perinatal care. And we talked about all of it and midwives who’d had children would tell their funny stories about being a breastfeeding person at the grocery store when their milk lets down. It engaged kind of a sense of humor. Like, who knew our bodies would do these crazy things when we’re least expecting it? and that was very, very helpful to me. And I was quite young when that started. So I had lots of run out room. It wasn’t hitting me in my 30s, where I’d learned to be very proper. I was a rebellious teenager, so it was great. I was like, great, bring it on. You know, when everything’s treated clinically and they’re too much gets left out. And which is why I’m so thrilled to see midwifery creeping into the more clinical parts of our culture. Really excited by that.

Ali Starling: [01:01:40] I mean, I think that ideally every patient or person deserves a midwife when they are laboring, even if they’re high risk or have to give birth in a hospital.

Esther Gallagher: [01:01:55] I would even say especially if you’re just going to squirt a baby out, who do you need, really? But I don’t mean to be cavalier, but we all need midwives, right? We all should get midwives.

Ali Starling: [01:02:10] Yeah. And I think in the fourth trimester, even so, just a mental health midwife, someone to check in on you that has some sort of clinical experience I think is very pivotal as well. Because it is so common. PMAD perinatal mood and anxiety disorders are so common. And so hopefully at UCSF and other places will pave the way for this to happen and nationally as well.

Sarah Trott: [01:02:48] Well, certainly we see some progress being made, and we hope that this conversation is listened to far and wide and helps with that effort. Is there anything else that you wanted to touch on? 

Ali Starling: [01:03:20] Yeah. Since I’m passionate about PMAD perinatal mood and anxiety disorders, and I realize how when somebody does have a mental illness, how it affects everything else in their body too, it affects their resilience. It affects their ability to cope. It affects their attitude and their mood and it affects their functioning. Right. So even what I find fascinating is you have patients that are at high risk birthing centers or high risk patients who are so optimistic and have such fantastic mental health and are thriving even though they have stage three breast cancer in our 32 weeks pregnant or have pre with severe features and have to be hospitalized at 30 weeks and or go into labor at 29 weeks, or to have a birth that they weren’t expected, a poor outcome. 

And it’s mental health that really helps pull them to get through these really trying conditions. So Esther, when you mentioned at the beginning of the podcast how we all, in the postpartum period go through ups and downs, but postpartum blues is like 80% of people will experience postpartum blues. You know, I recall when I was three days postpartum being in the NICU, and they were kicking my mom out at 8 p.m. and I was like, I cannot believe you were kicking my mom out at 8 p.m. pouring, crying, pouring. My milk wasn’t coming in. Horrible experience. I was like, this is how we’re treating our maternal infant dyad. I can’t even have a support person in the NICU. It was absolutely atrocious. But anyway, going back to your point and if you have a preexisting condition, a preexisting mental health condition, it can make this postpartum period that has, we already know, has so many ups and downs even worse and even harder.

Ali Starling: [01:05:33] I just want to say that you’re going to be okay. There is support out there and you’re not alone if you do have one of the many psychiatric or mental health conditions and there is help out there if you need and it’ll really help you get through intrapartum. So labor and delivery, which can be very stressful and joyful and scary and it’ll help you get through the postpartum period as well.

Ali Starling: [01:06:09] So and then Sarah, you had mentioned postpartum psychosis. I didn’t really want to focus too much on postpartum psychosis because it is pretty rare for it to happen.

Ali Starling: [01:06:21] But we do hear about it in the news quite a bit. every once in a while there’s like a news article about postpartum psychosis. But in general, ways to prevent postpartum psychosis are just like ways that I already mentioned to to prepare for postpartum anxiety or to prepare for postpartum depression. a lot of it’s preparation. And if you are predisposed to mental illness and you are on medications, I don’t recommend you to get off your medications when you are pregnant, recommend to stay on your medications and work with a healthcare professional that will be with you throughout your pregnancy and postpartum period. especially if you have a condition like bipolar disorder. Have you been if you’ve been diagnosed with bipolar disorder or schizophrenia or, certain health care conditions, I definitely recommend to stay on those medications. 

And then prepare for things such as sleep, prepare for social support, prepare for a lot of different scenarios, and that will help hopefully prevent that threshold into postpartum psychosis. But that being said there are some things you can’t prepare for, and there are conditions that happen no matter what you do. But definitely there are ways that you can think ahead.

Sarah Trott: [01:07:40] For sure. Thank you. We love to point people towards resources. If someone is listening and they feel like they would like to either find out more or reach out for help somewhere, are there any resources that you would like to mention in particular?

Ali Starling: [01:07:55] Yeah, sure. I mean, and maybe I could put these on your website as well. Massachusetts General Hospital has a really good center for women’s health that has a curriculum for perinatal psychiatry that is a well-researched and referenced center and documents that will be on your website. Mother to baby organization has loads of handouts and resources for people in the prenatal and postpartum period and a few others that I’ll definitely put on and give to you guys as well.

Sarah Trott: [01:08:36] Perfect. Thank you. And we always like to mention that Postpartum Support International has a free helpline. Just search for PSI helpline. And it’s always available. So I think it’s English and Spanish. So someone wants to just have someone to talk to because they think this may or may not apply to them. Then we highly recommend Postpartum Support International.

Ali Starling: [01:08:57] Yeah. And then just going to like your labor and delivery like triage um or the labor and delivery floor of your hospital too. So if you ever feel that you might be developing signs of severe moderate postpartum anxiety, depression and or psychosis and or any condition, they’re here for you. So really healthcare professionals want you to seek out support, want you to know that there are resources available. And please reach out to somebody at your local hospital.

Sarah Trott: [01:09:31] Great. Thank you.

Esther Gallagher: [01:09:34] Oh, I’m just so pleased that we. Got a chance to chat with you, Ali. 

Ali Starling: [01:10:05] Thank you so much for having me.

The content provided in this article(s) is provided for informational purposes only and does not constitute medical or other professional advice. Neither Sarah Trott nor Buckeye Media LLC (DBA Fourth Trimester) are liable for claims arising from the use of or reliance on information contained in this article.