Dr. Fox: Welcome to today’s episode of “Healthful Woman,” a podcast designed to explore topics in women’s health at all stages of life. I am your host, Dr. Nathan Fox, an OBGYN and maternal fetal medicine specialist practicing in New York City. At “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness.
Dr. Choukalas, Chris, welcome to the podcast. Thank you so much for coming. I appreciate it. How are you doing today?
Dr. Choukalas: Dr. Fox, Nate, nice to meet you. Thanks for having me. I feel good. Actually, you’ll appreciate this. I was on a labor and delivery call as an anesthesiologist last night. So, I’m caffeinated and ready to rock.
Dr. Fox: That’s true. So, for our listeners, when you say you were on labor and delivery call, you were there in the role of anesthesia.
Dr. Choukalas: Correct.
Dr. Fox: Not as a patient and not as an obstetrician, but that is…we’re going to get deep into that because of who you are, and what you do for a living, and your relationship to labor and delivery, and the book that you wrote. And so, it’s awesome. And I do have to give a shout out, obviously, to Julie Romero, who connected us two, who’s one of my fave peeps, former colleague, former student and resident, and continued friend. And so, thank you, Julie, for connecting us.
Dr. Choukalas: She’s terrific. I really appreciate her and her connecting you and I. And, yeah, she’s terrific.
Dr. Fox: So, you wrote a book recently that’s called “Even the Darkest Night: A Father’s Journey of Hope and Healing from Paternal Depression.” And in it, you describe…essentially, it’s like a memoir of sorts of you, your life that sort of stemmed from the birth of your twins and what happened to your wife and then the aftermath. And so, we’re definitely going to talk about that. But for our listeners, I guess, give us a sense of who you are. What’s the deal? You know, what do you do? Where do you live? What’s going on? And then we’ll talk about the book and everything related to that.
Dr. Choukalas: It’s funny, I’ve never been asked to say who I am. Because as a physician, particularly an academic physician, we’re used to kind of giving our resume. Well, I trained at the blah, blah, blah. And so, if you look at who I am now and where I am now, look, I live on a leafy suburban street in a bougie suburb of San Francisco. And I work as a physician in a private practice of anesthesiologists. And I have two beautiful girls, and a yard, and all of those things that you would look at and say, well, geez, this guy’s got it all figured out. But the path to get here was not a traditional one.
I grew up in suburban Minneapolis in the ’80s, the younger son of divorced parents, where our dad and mom divorced when I was about five and my brother six. And our relationship with our parents, you know, shifted dramatically. You know, we did the weekend thing for a while, but ultimately, our father remarried, moved away. And unbeknownst to us at the time, that would be the last time we ever saw or spoke to him. And it wasn’t like we felt abandoned. We didn’t really know. I mean, just time would go by and there’d be another birthday where there wasn’t a thing or we just…everybody kind of grew apart.
And so, after kind of 10 years, 15 years, like, oh, we don’t have a father. And you know, our mom did the best she could. She worked because we had to eat. And that left my brother and me on our own a lot to kind of figure out how the world worked, to satisfy the things inside of five and six-year-olds that seemed scary or uncertain, mostly left to our own devices to do that. And the only reason that I kind of mention all that is because what came later in terms of my own parenting crisis. You don’t have to look too deep under the hood to say, hey, wait a minute, this guy’s own upbringing was one of fear and anxiety, and put him in a position to have to provide something for his own children that he didn’t receive himself. And what an impossible situation that would be.
Now, add to that, that around the time our girls were born, we were in the middle of a pandemic of critical illness. And as an intensive care doctor at the time, I spent a lot of my days and nights caring for the sickest people on the planet, and seeing the kinds of things that humans aren’t really supposed to see in other humans. It’s like when you’re a witness to a car crash. You don’t necessarily think of it consciously, but your brain stem isn’t really supposed to have those images coming into it. Because it’s just so far outside the heuristic of what a human is supposed to expect in the orderly, predictable world around them. And when you have old people dying in an ICU, that’s orthogonal, but related to normal. But when you have people that look like you at your age, a 40-year-old healthy person dying, that gets pretty weird pretty quick.
So, against that backdrop, we are in the hospital giving birth to our twins, which ultimately required a C-section that became complicated by postpartum hemorrhage. In other words, my wife’s uterus did not contract normally. She ended up having a 20-unit blood transfusion emergency that then required a cesarean section that then required an additional surgery for internal bleeding. And so, you start with an unstable foundation, you have this environmental context of the world being completely disorderly, and then you watch your wife nearly die on the very operating table that you had spent your life rescuing people who are your own patients. But because I’m holding these girls, I’m powerless to do anything other than watch the experts dramatically rescue my wife. So, there you have it. So, then you come home and you try to resume some level of normalcy. And the wheels just kind of came off.
Dr. Fox: There’s a lot to unpack there.
Dr. Choukalas: Yeah. I’m sure you’re glad you asked. Yeah. Where do you start?
Dr. Fox: As a podcast, this is great, because now I have 412 follow-up questions to ask you. So, this is…thank you for setting that up. So, I guess, as our listeners have gathered and if they’ve checked out the book or whatever, that you’re a physician, you’re married, you’re living in California, you’re working, you’re an anesthesiologist, intensive care physician, you always take care of patients, you’re doing a lot of stuff. And COVID is there, which for everyone obviously was nuts, and particularly for doctors, and particularly for doctors who are working in the ICU. That’s literally ground zero for COVID disaster.
So, you’re there, and at the same time, your wife is expecting twins, which is amazing, your first kids. And you discuss in the book that to get to that point was a journey. Just to get to the point that you’re expecting twins is an amazing journey. And obviously, then you have this crazy situation at delivery. I want to ask you about that day.
So, you’re there with her. Again, you’re a doctor, you’re in the middle of all this. There’s so much swirling emotions, excitement, fear, all the sort of “normal” things before the birth, and then all hell breaks loose with your wife. And you’re a father, you’re a husband, you’re a doctor, but you’re not her doctor. What was that moment like, watching it? What is going on in your head to be in the room as everyone is doing the things that you would normally be doing, but it’s your wife, and you’re holding your kids?
Dr. Choukalas: One of the seeds for wanting to write about this was that there was this really kind of fucked up way that I felt sitting there holding these babies and looking at the monitor over my wife’s shoulder while in the labor operating room. And the cognitive dissonance between watching all of this normal stuff happen, and everybody’s behaving calmly and following their routine, and I’m holding these babies, and they’re having me cut the cords, and they’re taking pictures, and I imagine behind the masks, everybody’s smiling. And yet I keep looking up over my shoulder at the monitor, and I’m seeing 60 over 30. So, it’s like my brain stem was tingling, but yet there was all this other information coming in that seems like it was normal.
And then at one moment, I kind of snapped to, and I looked back at the anesthesia workstation, and I’m seeing this morass of empty syringes with the labels of all the medicines that we use to bolster people’s blood pressure. And so, then I’m like, oh, shit. And I stood up, and I looked over the drapes, and I saw the externalized uterus, and it looked like a beach ball. I mean, it was this big, inflated, baggy thing. And I’m like, oh, this is what’s going on.
And so, then I’m kind of able to attune to the fact that the anesthesiologist is putting in a third peripheral IV, and she’s calling at one point for the cross-matched blood and then for the O-neg blood, and then for the massive transfusion protocol and the Belmont, which is the machine we use to heat and transfuse large amounts of blood all at once.
And so, it just seemed like, very quickly, it was going from normal to not normal to really not normal. And yet I’m holding these babies. And so, it was very, very bizarre. My wife thought, in retrospect, she’s like, that dissonance is not interesting to people. And so, don’t spend so much time writing about it. And I was like, no, that’s the whole book, because I’m such a [crosstalk 00:10:42]. I’m like, that part is fascinating to me. And she’s like, nobody cares about that.
Dr. Fox: There’s nothing better than having a wife or a partner, because you’ve got this whole thing to like, dude, no one wants to hear that.
Dr. Choukalas: Nobody cares. Yeah.
Dr. Fox: You know, it’s interesting because people ask me all the time, like, did you deliver your own kids or, you know, my daughter’s had a baby, were you…did you take care of her? And I’m like, you don’t get it. That is such a bad idea. People who practice medicine are like that is the worst idea in the world, because if anything goes wrong, you will fall apart because you can’t possibly deal with the idea that it’s not…it’s a patient, it’s a relative. It’s just too much for a human brain to function properly. You sort of have to be somebody else.
And so, you are being that other person. And so, it’s sort of the opposite. It’s almost like you’re…one part of your body is like, jump in, jump in, jump in. But the other part of your body is like, no, I’m the dad here. I got to hold these kids. I have to let other people do it. But that is fascinating and it’s complicated. It’s hard, emotionally, and just sort of cognitively what to do in that situation.
Dr. Choukalas: Well, and I was blessed by the fact that because I was on faculty at UC and I was at UC, to be able to know and trust that my colleagues were experts at what they were doing. And in fact, it is a…UCSF is a center for abnormal placentation, which is just a fancy way of saying they get patients who bleed after delivery a lot, and they practice, and they simulate, and they have protocols. And so, postpartum hemorrhage is something that they…that doesn’t even raise their heart rate.
And so, looking at the whole thing in retrospect like, hell, they did everything right. I was more worried than they were. Helping them somehow, even if I could have, would not have been…would not have appreciably done anything. I feel great about what they did and how they did it. And so, it wasn’t like, oh, I need to jump in because they’re not doing it, but it was like…it just was a really weird, terrible feeling.
Dr. Fox: And I’m sure for them also, the fact that this is their colleague, who’s sitting next to them. And it makes it stressful.
Dr. Choukalas: Yeah, a hundred percent.
Dr. Fox: Yeah. Ultimately, thank God, she…they took good care of her. She did well. Your wife, your babies, all are okay. And at some point, you’re all at home. And tell us what happened once you sort of…you’re in fatherhood now, parenthood, the two of you.
Dr. Choukalas: Yeah. So, now, we’re home. And you’ll probably get a kick out of this, but as an intensive care physician, you’re used to these big charts and flow sheets and lots of cells with lots of data in them. And so, I’m thinking, okay, well, we need to keep track of who’s peeing and who’s pooping and when and how long.
Dr. Fox: Did you round on the kids this morning? Am I rounding on the kids this morning?
Dr. Choukalas: I’m rounding on the kids every day. So, I’m making an Excel spreadsheet, and it’s got chart for the tables and the whole thing. And my wife and her mother who is staying with us to help out at the time, they’re just kind of rolling their eyes. But that was kind of the start of feeling the need to control something that ultimately is uncontrollable. And as time passed, I became less obsessed with that and more obsessed with kind of these rigid routines around sleep and feeding and trying to conform to this ultra-restricted rhythm so that I could feel a sense of peace and normalcy. And it became an act of almost like punishing the joy that Lindsey was taking from parenthood by being this domineering force trying to control the uncontrollable, and consciously because I thought, oh, because this is right for the girls, but really as time passed, it just became clearer and clearer to Lindsey at least that, no, I was trying to control something in me.
And as the weeks became months, I was realizing that I was spending my entire day with this anxious sensation in my belly and my chest. And I spent a lot of time in the book trying to describe what anxiety felt like, but it was this gnawing warm kind of electrical pulsing in my belly and my chest. And it would attack during the day, it would attack at night, it would attack… And it was just the predominant feeling anytime the girls were awake.
Dr. Fox: Were you working during this time, or were you home during all this time?
Dr. Choukalas: I was off for a few months, and it straddled both my home time and my work time. And going back to work after a couple of months did give me a bit of a respite from it, but the second the phone would ring and Lindsey was calling or as morning turned to afternoon and my impending return home was getting closer and closer, it would just fill me. And I would do all kinds of things to try to make it go away from drugs to long drive home to sitting in the garage to just trying to be away from this feeling. But ultimately, nothing could make it go away except those rare moments when they were asleep and I knew they were asleep and I could finally breathe.
And so, finally… And all this time, I’m thinking, this is what being a parent is. You have to…I’m just gutting it out. And when Lindsey finally comes to me with this idea that, you know, I talked to somebody, they’re a psychologist and they think men can have postpartum depression, too, and I think you have this. And it felt like one more thing. It felt like, okay, well, now, I got to worry about that, too. And our relationship and our way of relating to each other had so deteriorated at this point, I’m just like, why…I’m probably even yelling, like, why do I have to have a thing? Why can’t you just get on board with what I think we all need to make this go, to make the trains come on to them? And it’s just we were on two different planets.
Dr. Fox: How long did it take between Lindsey recognizing that there was something wrong, let’s say, so to speak, or that there was something clinical as opposed to just parenting troubles, so to speak, and for you to get on board with that, that you realized that you needed help? Was it a matter of days, weeks, months?
Dr. Choukalas: I think it was days, because I knew I was unhappy. I just didn’t know why. I thought it was because I’m bad at this, I’m a bad partner, and we just aren’t going to see eye to eye on this. And everything is a fight, and I’m unhappy. And so, I thought, at the very least, if I talk to a therapist, I’ll be able to unload that. At least I’ll be able to get some support around how unhappy I am and how terrible this all is.
Dr. Fox: I think our listeners are pretty used to hearing stories about postpartum depression, postpartum anxiety. And probably a lot of them have familiarity with it, either unfortunately for themselves or maybe loved ones or certainly maybe they know somebody. But I suspect a lot of them have never heard of the idea that a father could have postpartum depression or as it’s called paternal postnatal depression or anxiety. So, can you talk about that a little, about what it is and what you’re experiencing and what you learned about it? Because it was something you had never heard of either at the time.
Dr. Choukalas: Yeah. I would not have ever thought of this. And in fact, in addition to being a doctor who did rotations in psychiatry, I have a master’s degree in psychology from my days before going to med school. So, it’s like I theoretically should have known that this was a thing that could happen, but I didn’t. And it never occurred to me that I had something clinical.
You kind of tripping over the name is really important because, as it happens, people have really strong feelings about the name. So, there are people out there who feel like just using the word postpartum is an affront to women and that it is stealing the thing that is uniquely theirs. And even postnatal stimulates very strong feelings, at least in the social media hate chamber of trying to kind of tear people down. And what I’ve realized is that there are a lot of people out there who have been really harmed by the way that their feelings and experiences have been treated by friends, families, spouses in the medical profession, and that there needs to be a real sensitivity around how we talk about mental health in the perinatal period for both parents.
What I’ve learned about the syndrome is that we call it something that sounds like postpartum depression, but the phenomenology is super different. So, if you go to postpartum depression for women, this is an official DSM psychiatric disorder that has a name and a definition. And the definition is a major depressive episode within weeks or months of delivering the baby and a major depressive episode has its own criteria, sadness, and guilt, and shame, and weight changes, and sleep disturbances. And that sounds like depression. If you say, what does depression look like, that would fit.
But if you go out and type into Google, you know, postpartum depression in men or postnatal depression in men, you get this symptom list that looks really different. You get anger, and irritability, and conflict, and risk taking, and drug seeking, and anxiety. And that’s really what I had. I wasn’t sad or didn’t feel sad. I didn’t feel shame. My weight didn’t change. But I had all those other things. And so, when I saw that, I thought, oh, this really fits.
The other kind of set of things that I’ve learned and that I try to kind of bring up for people as they wrestle with a man talking about perinatal mental health is the very real set of data showing that lots of people who don’t carry and deliver a baby can have mental health disturbances after delivery. So, men, fathers, adoptive parents, non-carrying same sex parents. There’s a research psychologist at USC named Darby Saxbe. And she actually put out a book right around the time that I did called “Dad Brain.” And we’ve had a lot of conversations about this in real life and in social media. And she’s a tremendous resource in this area because she’s done a lot of the primary research basically showing that, yeah, it’s great for women to say that they have these huge hormone shifts and that’s why they have postpartum depression. But I’ve studied men my whole career and they have hormone changes, too. And I put a thousand men in the MRI scanner before and after they have their babies, and their brains change, too. And I’ve done this with adoptive parents and like…
And so, on the one hand, it’s like, you say those things and it’s like, well, is that stealing from women’s experience? Or do you say, hey, everybody is at risk for mental health disturbances and the transition of parenthood? We need to be paying attention to all of the parents because all of them can be affected.
And I’ll take it one further. JAMA, the Journal of American Medical Association, maybe about 8 or 10 months ago now put out a meta-analysis looking at pediatric outcomes along a host of domains like intelligence, social and emotional outcomes, and things like this. And when children were raised with fathers who had anxiety or depression, those outcomes were worse. And so, you want to be sensitive to women’s experience. But on the other hand, if you’re going to ignore the non-birth parents’ mental health, you’re also putting your kids at risk.
Dr. Fox: Yeah. I mean, it makes sense, number one, that there would be…that there could be hormonal changes in parents who don’t carry and deliver a baby, but also mental health related to major life events is not only hormonally driven. You can have mental health issues that come up related to marriage, related to death, related to stress over a job, related to anything. And having a new baby or babies or watching someone almost die or whatever it is can be…can absolutely trigger mental health issues for people.
And so, it’s…I think it’s obviously both. I think the women who carry and deliver babies uniquely will have major shifts in hormones to a larger degree maybe than others would. Okay. Terrific. And probably, statistically, predominantly, they’re the ones who are going to have…be at risk for postpartum depression, anxiety. All true, but that doesn’t negate the fact that others could also. And at the end of the day, who cares? Why not try to have everyone’s mental health be optimized and be cared for and be watched for? Like you said, anyone who’s a parent, and with anything, even if you’re not a parent, obviously, if you’re suffering, you should be cared for. And so, it’s really…I get why there would be a fight, so to speak, over this. I totally get it. But at the end of the day, it really doesn’t matter if someone’s suffering. It should be recognized and helped.
Dr. Choukalas: Well, here’s what I think is happening. And I learned something in my doctoral program in counseling psychology that has stuck with me my whole life, that if something is irrational, it’s not about the facts. It’s about the emotional experience of something. And I think, when I see… And again, predominantly women, but sometimes men, too, really holding on to the hormone hypothesis of postpartum depression. That is to say, postpartum depression is hormones and hormones are postpartum depression, which, by the way, not settled science at all. But that people really hold on to that role of hormone changes as the sole contributor to postpartum depression. So, therefore, men can’t have this because they don’t have this hormone thing.
The vehemence with which people cling to that is obviously not rational. And so, what is the emotional experience? Well, I think, based on nothing, that, look, mental health is stigmatized. People really want to have a biological explanation for this syndrome so that they don’t have to grapple with the fact that they have a stigmatized mental illness. And so, the degree to which this is hormones, they don’t have to grapple with the stigmatized mental illness because it’s hormones. And so, if you start saying people without hormones have this, too, then you now have to face this feeling that you have something that isn’t medical, but mental.
Now, I don’t make that distinction because I do this for a living, and I don’t have the shame of having a mental illness. But lots of people do, understandably so, because the way our society treats people like this. And so, I think that in part creates the block for people around not wanting to see this as a broader thing for people. That’s my opinion anyway.
Dr. Fox: I think that makes a lot of sense. Chris, I think what I’d like to do is I think we’re going to pause here, and we’re going to pick it up next week. And I want to focus in that podcast on your decision to write a book about this and sort of how you plan that, how you did it, and what the response has been. So, hang with us. And for all our listeners, we’re going to pick it up again next week.
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