CHRIS AIKEN: Psychoanalyst William Meyer shares with us a therapeutic approach to postpartum depression.

KELLIE NEWSOME: Welcome to The Carlat Psychiatry Podcast, keeping psychiatry on since 2003.

CHRIS AIKEN: I'm Chris Aiken, the editor-in-chief of the Carlat Psychiatry Report.

KELLIE NEWSOME: And I'm Kellie Newsome, A psychiatric NP and a dedicated reader of every issue.

CHRIS AIKEN: I ended last week's podcast with some hope that zuranolone may spare some women with undiagnosed bipolar disorder from taking antidepressants in the postpartum phase, and in fairness, psychotherapy, light therapy, TMS, and ECT also protect women from that problem. A common problem that affects somewhere between 15 to 50% of women with postpartum depression who actually have unrecognized bipolar disorder. Today, we're going to look at the therapeutic approach. One honed by the late William Meyer, a psychoanalyst at Duke, who spent most of his career helping women with postpartum depression through individual and group therapy. We caught up with Dr. Meyer at his home in Chapel Hill, North Carolina, shortly before he passed in 2021. He had built a small hexagonal-shaped therapy office in the front of his yard with stained glass windows, and we interviewed him in that holding environment.

KELLIE NEWSOME: Bill, what do you see as the cause of postpartum depression?

WILLIAM MEYER: A lot of times, we will see in studies reports that we'll say We don't know what causes postpartum depression. This isn't true. We can always learn new things, of course, but this is an area that's been studied up one side and down the other, and we know a number of things. We know that women who are depressed during pregnancy are at special risk. We know that women who do not feel supported by their partners are at special risk. We know that women who have had unhappy childhoods are at special risk. We also know about the things that help women, and it can be any combination of psychosocial, biological, including support groups, which I really haven't mentioned, but I think we are failing this group as a society, and I think that we can all do more and should do more. I think what happens in the earliest weeks and months, um, has everything to do with what will be the bedrock of our society.

KELLIE NEWSOME: What does that look like in the women you've worked with?

WILLIAM MEYER: When I see somebody who's struggling with depression or struggling with anxiety, and almost always it's some admixture of both, what I find is that there's a story that needs to be told. It may be a story that involves the fact that she's not getting support from her partner. It may be that she's trying to go back to work too soon. It may be that she's still recovering from a traumatic labor and delivery. Maybe breastfeeding is not going well at all, and everybody is putting pressure on her and adding guilt to what she already feels. It may be that she's sleep deprived, and so there are so many factors that are involved. What I often say to women that I see, when I hear how little support they have as I remind them of the well-known saying that it takes a village, and it does take a village, and so many women simply don't have a village. And so, when they find that they're really stressed and anxious and depressed, it's not because there's something that is wrong with them. It is because the circumstances in which they're living are inadequate, wholly inadequate.

KELLIE NEWSOME: We are trained as healthcare providers to support breastfeeding. But how does that play out with women with postpartum depression? How do you approach that?

WILLIAM MEYER: I think we place an enormous guilt trip on mothers about breastfeeding, and for some women, they're either unable to breastfeed, or it's not going well, no matter what they do, they've had many lactation consultations, but they are going to torment and torture themselves, to be up, to be sleep deprived, to make sure that baby gets breast milk for weeks or months at a time, irrespective of what their mental and emotional state is. I think this is a very personal decision for mothers to make. The message that I do try to convey to people, and some people have felt that the benefits to breastfeeding have been overhyped, and I think there's evidence to support that. What I do say to mothers and what I say to other practitioners who deal with new mothers is that if there is a question between whether that baby has breast milk or a mother who is enjoying her baby and feeling well emotionally, hands down, there's no question that the latter is much more important and much more vital for that infant's wellbeing.

KELLIE NEWSOME: Bill, it's very hard to build a social network when depressed. How do you recommend they do that? What are some ways you do that with postpartum depression? Social support groups, social media, calling old friends and family?

WILLIAM MEYER: I think it can be any of these things. And sometimes I think being able to call on extended family, even those who may be living out of state, tell them that they're needed, whether it's siblings, whether it's parents, and so forth. Sometimes I think it can be, a woman may be going home to stay with her parents for a time so that she can rest and recoup. In most cultures around the world, there's a period of about six weeks in which the grandmothers, the mothers, the aunts, all get together to take the baby from the mother, bring the mother food, care for her, nurture her so that she, in turn, can nurture the baby. That's how it's supposed to be, and it's anything but that in the culture in which we live, and it's terribly unfortunate.  

KELLIE NEWSOME: Tell us about what you've observed or experienced with the women, and the role social media plays in their need for connection. Is it a negative or a positive?

WILLIAM MEYER: Both. And I think too often women, and men, I mean, I'm not singling women out here, but I think we'll post only the smiling, happy pictures of themselves and their babies and so forth. And then when a typical mother looks at that and her house is a mess, and she's got spit up all over her and she can't get the baby to stop crying, and so on, she may feel like she's a failure or she's inadequate. At the same time, I think. In those areas of listservs and opportunities to connect with other mothers, where people are really talking about what the real experience of motherhood is like, I think these things can be lifesaving.

KELLIE NEWSOME: Before we met, I checked out the research, and I was impressed to see the psychodynamic therapy has just as much evidence in postpartum depression as CBT. In fact, in one large study, it worked faster. What do you think your background as a psychoanalyst brings to this work?

WILLIAM MEYER: One of the things that I think is most important and most helpful about a psychoanalytic perspective is its focus on understanding human development. So, what we know is that a new mother is going to fare well, optimally, when she herself had a good experience of being mothered as she was growing up. I think the other thing that's very important, of course, is that she feels supported can in her day-to-day experience now. I think mothers who had very difficult experiences with their own mothers sometimes have doubts about their own capacity for mothering. What we've found time and again, however, is that if they get the right support, if they get the right information, then they can learn that they can distinguish what they have to offer their babies and their children, that was good that they got, if not from their own mothers, from other experiences. I think too we come to know something about bonding and about attachment and about what babies need and how mothers can provide this. What is often referred to as the holding environment, and this is something that is derived from a psychoanalytic perspective. The holding environment is something a mother provides for their baby, but she herself, the mother, needs a holding environment as well. She needs to feel held and cared for by her community, by her family, by her partner.

KELLIE NEWSOME: So a woman's experience with attachment as a baby or a child can impact the way that they parent or the way that they feel or experience motherhood, sometimes immediately after they deliver.

WILLIAM MEYER: Absolutely, and sometimes, again, sometimes some gentle reassurance, I think it can go a long way.

KELLIE NEWSOME: How do you see the role of medication in postpartum depression?

WILLIAM MEYER: Yeah, I think it would be a mistake to put one versus the other. I do think that there are times when the prescription pad is reached for too quickly. Somebody just may need some sleep, and they may need a place to talk and to put them on a medication that they're going to be on and have to commit to for months at a time. I think is a mistake. At the same time, I think that one can err in the other direction that medications can be withheld, for a mother who's really anxious or she's really depressed and needs to get something started, I think it becomes very important for psychiatric providers to know about, first of all, about medications and which medications are safe for pregnancy or breastfeeding and so forth, because it's happened time and again that people will come to a mental health provider, medication provider, and be in need of a medication. They'll be told, Well, you have to go back to your ob. They go to the ob. The OB says You have to go to the psychiatrist, and so on. Aside from that, I think one of the most important things is what I think should come naturally to every provider in mental health and psychiatry. Is the capacity to listen and to be affirmative of what a woman may be going through, and to not dismiss concerns that she may have, and to be hopeful about the prospects for the future and to follow up often very quickly, and sometimes it can be a phone call, sometimes it can be a subsequent visit, but nothing like, Here's a prescription for X medication, come back and see me in three months, that just can't work.

KELLIE NEWSOME: What role do you see for brexanolone in postpartum depression?

WILLIAM MEYER: I don't have any experience with this medication, but I can say the vast, vast majority of women that we've provided, the more conventional medications, and psychotherapy, and social support have improved and done very, very well. So, as far as that goes, there are many treatments that I think have a ton of evidence about their efficacy.

KELLIE NEWSOME: When a pregnancy is unwanted or unplanned, it's a major risk factor for postpartum depression. This year, we've seen movements to restrict access to abortions, or even, in some cases, to make them illegal. How do you see that affecting the population of women you work with?

WILLIAM MEYER: Well, my own feeling about it is that I think the government's intervention involvement in these kinds of very serious areas that are medical, that are psychological, I think it is really a tragedy. We now have a support group that I have to do if it had been the case that they were prevented from doing this. I can't imagine how much worse their situations would be. The question about whether to terminate a pregnancy is nothing I've ever seen anyone take lightly, and it's usually a very thoughtful, important decision that's made between a woman, her family, her loved ones, and her healthcare provider, and I think that's the way that it should be. I understand that, you know, we need as a society to also set some restrictions on at what point abortion should be made legal and so forth, and under what circumstances. But I think these are too often done in great haste, and I think to score political points and really have very little to do with the needs of a mother or an infant.

KELLIE NEWSOME: Thank you, Bill. Join the Carlat conversation online through the Daily Psych feed. Search for Chris Aiken, MD on LinkedIn, Twitter, Facebook, and that new one, blue sky. Thanks for tuning in and helping us stay free of industry support.