“Postpartum and Perinatal Depression Part 1” -with Dr. Emily Miller MD MPH

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’m your host, Dr. Nathan Fox, an OB-GYN 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. Emily Miller, welcome to the podcast. I’ve been chasing you for a year now, and finally, I got you. You’re on the podcast. So nice to talk to you.
Dr. Miller: So excited to be here.
Dr. Fox: What’s going on how’s life in the windy city?
Dr. Miller: It’s, I guess, akin to life all around. You know, living in a pandemic definitely has its changes. I wish we were not continuing, but, you know, we’ve got some tools in our toolbox and we’re one foot in front of the other.
Dr. Fox: Love it. And we were talking before offline that you’ve got a…you’re starting kindergarten. Well, not you personally, but…Emily Miller is a physician but she’s in kindergarten. You’re gonna be a kindergarten mom.
Dr. Miller: Yeah. My oldest is going to kindergarten and my youngest is about to start preschool. So very dynamic and actually learned a lot more from my kids than they have from me. They teach you a lot of very humbling lessons.
Dr. Fox: Yeah. Well, you are knee-deep in the child-raising stage and I have a lot of empathy, sympathy, and love for you because of that. Excellent. Well, you are amazing. You are a physician, you’re an MD, you’re an MPH. You’re an assistant professor of OB-GYN, maternal-fetal medicine, and psychiatry at Northwestern. How’d you pull that off?
Dr. Miller: I know people. No. I mean, I’m just really lucky. The environment here is fantastic and really collaborative. And my research spans perinatal health outcomes in the mental health space and health services interventions for folks with mental health conditions. And so the Department of Psychiatry was willing to take me under their umbrella and it’s just been great to span both worlds. You know, obviously, I was trained formally to speak obstetrics, and to now be able to speak a little bit of psychiatry has been a lot of fun.
Dr. Fox: So our listeners get a sense of who you are, where are you from? How’d you get into medicine in the first place? What’s your story?
Dr. Miller: Yeah. Sure. So I grew up in the Southeast, but I’ve worked really hard to get rid of my Southern accent. It’ll pop out every now and again. So you might notice it. Migrated really specifically to colder and colder climates throughout my training and really landed for residency in Chicago. While it could get a little colder, this is kind of as far as I could extend the temperature. So I’ve been here since residency, did my MFM fellowship here, and stayed on, on a worker, a NIHK12, to really expand my research in perinatal mental health and now I’m entering my, I think, seventh year as faculty.
Dr. Fox: Wow. How’d you get interested in medicine in the first place?
Dr. Miller: You know, I come from a family of musicians and…
Dr. Fox: Oh, that answers it.
Dr. Miller: Yes. That’s obvious. Seemed like a natural segue. But, you know, they knew some people that were in medicine. And, you know, in my simple mind, the only people in medicine I knew were doctors. So I just said, that sounds cool and I wanna be a doctor. And I’m stubborn and, you know, when I have a goal, I just am a dog with a bone. So I did that. And, you know, really love the concept of a career that’s built on the principles of being able to apply science, apply…in my mind, research is an art form. It’s a tapestry that, you know, get to create to be able to answer questions. And, you know, it’s such a fulfilling job that we have, to really get to take care of people. So that’s what I did.
Dr. Fox: That’s great. And then when you were in med school, at what point did you know you wanted to do OB-GYN women’s health?
Dr. Miller: It wasn’t until my OB-GYN rotation. That was the furthest thing from my mind.
Dr. Fox: Really? What did you think you’d be doing?
Dr. Miller: Actually pediatric infectious disease was something I toyed with, just the global health implications. And again, you meet inspiring people and say, “Well, that sounds great. I wanna do this.” And not really having any context or family that was in medicine, I just kind of didn’t know what to expect with anything. And then on my OB-GYN rotation, just had amazing mentors, just really inspiring from the interns to the residents to the attendings. And this is really dynamic field and vast opportunity for things to do. I knew I wanted to integrate clinical research into my career and it seemed like a sphere where there are a whole lot of questions that haven’t been answered. So it would be longitudinally fulfilling.
Dr. Fox: Is that why you got your master’s in public health as well?
Dr. Miller: I knew I wanted to do research and get some foundations in [inaudible 00:04:48] outcomes research. And so it felt like a time to take a step back and get those tools in my toolbox so that I could apply them throughout the rest of my training. I mean, the other piece, to be honest, is I was floored that I wanted to do OB-GYN and that’s just a huge pivot when you’re not speaking about that career path. And so having that extra year, I took a year between my third and fourth year to just reflect on what this would look like and make sure this is truly what I was committed to. It just gave me a little bit of breathing room to think and reflect and be sure before marching forward.
Dr. Fox: Well, you ultimately did it and you ended up in Chicago. And I’m gonna ask you two questions about Chicago. Number one, how long did it take for them to convert you into a Cubs fan? And the second is how you decide to pivot…not pivot, but maybe go into the field of maternal-fetal medicine. So start with the Cubs.
Dr. Miller: Yeah. Most importantly. I will say I lived in East Lakeview. And it’s a takeoff of Lakeshore Drive is kind of what’s taken by effectively all of Chicago on Cubs game nights. So I became a little bit less of a Cubs fan because it extends my commute fairly dramatically, and I’m agnostic to baseball. If it’s not, honestly, soccer, then I don’t generally watch the sport much to the chagrin of the rest of my family.
Dr. Fox: Oh, dear. Well, we’re gonna…maybe we’ll edit that out so people don’t just dislike you for that, for not liking the Cubs. Okay. But that’s fine. I understand you live in the neighborhood. It’s tough. The lights are on, people walking around, a lot of stuff going on. It’s not quiet, that’s for sure, on game nights. So it’s all good. Okay. So not the Cubs, but you definitely are a fan of maternal-fetal medicine because you did that. So what brought you into our neck of the woods?
Dr. Miller: Yeah. You know, I became really enamored with obstetric practice. Again, knowing I wanted a career in clinical research, it’s just an area where we have so many opportunities from a translational science standpoint, from a clinical trials standpoint, from observational data and the nuances of interpreting observational trial, observational data. From health services standpoint, I think there’s so many opportunities we have to improve the care that we deliver to and improve intergenerational outcomes. So I felt like it was a space that was certainly right for clinical research, but it’s also such a rewarding area to navigate through difficult complexities and the pregnancy with an entire family and kind of be that anchor for that family during difficult decision-making.
Dr. Fox: Yeah. And, you know, this podcast we’re doing today is gonna focus on, you know, postpartum, let’s say, postpartum depression, for example. How did you get so interested in that specific area? I mean, clinically, research, advocacy, I mean, you are really in there and you’re doing a ton of amazing work for, you know, people who are either suffering from this or have family members suffering from this or worried they may suffer from this or whatever it is. How do you get involved in that specifically? Because it’s a little bit of a niche for maternal-fetal medicine.
Dr. Miller: Yeah. I appreciate that question so much. And there’s a million stories I could tell. I think one that really resonates that was a pivotal moment for me was a patient I cared for. She was a pregnant person living with HIV and she had perinatally acquired HIV and had lost her mom to AIDS when she was young, when she was 3 years old. Her father had substance use disorder and so she was in the foster system, foster mother died of cancer when she was really young, just all of this childhood adversity. And then, you know, this was in the early ’90s, living with HIV as a child, as an adolescent, when these medical regimens are complex. And so needless to say, in the face of all of this adversity, she developed very significant depression and anxiety.
And then fast forward to, you know, she becomes a young 20-something person and is on very complicated HIV medications because she’s developed a lot of resistance just, you know, due to the complexities that I described before. And she wanted a family and had told her pediatric ID doctors, “I wanna get pregnant because having a family…” she’d never really felt like she had one and that was going to be pivotal in her wellness and this is something she’d really strived for, even though her viral load was over 100,000 and she wasn’t taking these medications. And so I co-run our women’s HIV clinic and assumed her care when she actually was admitted to our hospital with PJP pneumonia, viral load sky high, strong history of depression and anxiety.
And, you know, we all came together, social, psychology, ID, MFM, pharmacy, you know, all the things, and we got her back on medicines and we got her viral loads suppressed. And it was just this really exciting time where we felt like we had reached her. She didn’t have any episodes of major depression throughout the first half of her pregnancy and we were so excited that we had finally reached her after, you know, the pediatric team had tried for years.
And then at 24 weeks, she stopped showing up to our clinic, and stopped answering our phone calls, and stopped answering the door for the case managers that were coming to visit her. And we, you know, did everything we could to return to reach her in the clinics and she presented to the hospital with shortness of breath at 32 weeks with recurrence of PJP pneumonia. And what had happened is there was, you know, family termoil with one of her siblings and it had precipitated another major depressive episode, and that really unraveled everything that she had done to get to where she was. And she developed ARDS, ended up being intubated, going into preterm labor, delivering this beautiful, healthy baby boy. And she died three weeks postpartum and she never got to know consciously that she had become a mother and, you know, her goal of having her own family, she had achieved.
And I’m just convinced that, you know, we have all of this expertise in HIV perinatology, antiretrovirals, and management of AOVS, and critical care obstetrics. And that’s awesome. That’s fine, but if we had been able to reach this person’s major depressive episode and effectively treat her, I’m just convinced she would still be with us today. And so it just amplified, you know, this perspective, if we, as maternal-fetal medicine physicians, do not incorporate mental health into our practice, then we really can’t call ourselves internal medicine physicians. And so that just got the ball rolling and made me committed to filling the gaps where they need to be filled and advocating, educating, doing the things.
Dr. Fox: Your story is so poignant because I mean, someone would say what’s the cause of death? And it’s, “Oh, she died of pneumonia.” No, she died of depression. Right? And it doesn’t mean she took her own life, right? That’s one way to die of depression, but basically, it’s what ultimately ended her life. And that’s, you know, when we have these conversations with women either before pregnancy or early pregnancy, you know, who struggle with mental health and we’re talking about treatment, you know, to those of us in the field, it’s like mind-blowing how all the messaging they’re getting is medicines are going to hurt your baby. Right? The medicines are gonna hurt your baby.
And, first of all, it’s not true. Okay. But even if there’s some risk, right, and there might be some risk, right? It’s not zero risk, but it’s very, very low. But whatever it is, how about your depression might hurt your baby and might hurt your baby’s mother who’s gonna hurt the baby? And so people just totally blow that off and they’re like, “Well, you know, like, whatever. You know, you could, you know, suck it up for the pregnancy and just take the meds after you deliver.” Like, no, that’s not how it works. These are real issues here.
Dr. Miller: No. You’re totally right. There’s this great…I mean, here’s my scientific reference, “Huffington Post.” But…
Dr. Fox: It’s a medical journal. Yeah. You know? In Latin.
Dr. Miller: Yeah. Totally. On PubMed. But it’s this image and it’s, you know, all of these cartoons of somatic illnesses and then, kind of, inserting depression and there’s, sort of, this person that’s over a toilet seat throwing up and their friend beside them saying, “Have you ever, you know, tried just not having the flu?” And, you know, so obviously, you know, it’s in jest, but it’s this concept that we do that with depression. And it’s a major medical illness. There’s neurobiology behind it. And, you know, we would never conceptualize it like, “Hey, you know what, just snap out of that preeclampsia. Stop doing that. Or don’t have diabetes. Just don’t.” But we do that with depression. And I think we as just humans stigmatize mental illness and say, you know, pregnancy or not, just try to muscle through it or be stronger than that instead of recognizing it as the disease that it is.
Dr. Fox: Right. It’s like what does this person have to be cancer about? Their life is so wonderful. Why would they have cancer? Everything’s going great for them. That doesn’t make any sense. You know, it’s like you’re like, “What?” It makes no sense whatsoever, but it’s the same thing. Like, someone who has an anxiety disorder or depression, it’s not that they’re just like not coping with things because they’re weak. It’s like, that’s a real serious illness. It’s a situation and it’s…listen, that’s why I’m glad you’re on. What is it that you would say? I mean, obviously, it wasn’t new to you when you came to maternal-fetal medicine. This is something that obviously you saw through medical school, and residency, and your fellowship, but I’m just curious, is there anything that, sort of, was like a light bulb to turn on, like an aha moment about understanding how critical mental health was? You told a story, was it at that story, or was it something that maybe before just brought it to light?
Dr. Miller: Yeah. I mean, I think a lot of it is…You know, there’s a story that comes to mind often and I reflect, obviously, on that particular patient and the impact, you know, that I will carry forward for the rest of my careers is gonna be there. I think we can all think about examples of when we just haven’t been able to reach a person or we haven’t been able to have that connection or the outcome hasn’t gone in the same way and I think those are oftentimes…not always, certainly, but oftentimes we do not cover, you know, both what are the psychosocial, what are the mental health, what are the social structural determinants of health that played a role? And I think we were just not taught that in medical school in the same way, or historically, you know, 100 years ago when I went to medical school it wasn’t talked about.
Dr. Fox: You went 100, I went 200, so thanks. Yeah.
Dr. Miller: But I also think we do hard stuff in MFM, right? We manage complex cases, we will, you know, titrate antiarrhythmics for fetal benefit that, you know, thinking about it in multidisciplinary ways with our electrophysiologist, like we do weird, complicated stuff. Screening for depression is really not that hard. And, you know, I’m not suggesting that we all become psychotherapists, that would be great, and that would be cool, but, you know, that’s not within our sphere. But the pharmacotherapy of depression/anxiety is also not that complex. And when we can talk about, you know, giving anti-rejection medications for someone with a transplant in the nuanced fashion that we can, it’s hard for me to imagine why we feel like we don’t need to do that for pharmacologic therapy for mental health conditions. And so that’s where I think with the support behind us, it’s something that is within our wheelhouse to be able to talk about it, to be able to dose, manage, up titrate. These are not foreign concepts to us. I think we just need to develop this fluency.
Dr. Fox: Yeah. I mean, I would say, for me, I feel like I didn’t get enough of this in medical school, and even residency, and probably fellowship. I don’t think I really began to appreciate how much mental health plays a role in health overall and also in pregnancy until I was in practice and you’re actually…because you’re seeing so many more patients and you have much more of a relationship with them and you get to know them and talk to them and I’m like, “Oh, my God, so many people, right, have anxiety, have depression, have OCD.” And it’s part of their health and you have to talk about it all the time. And I don’t mean that in a negative way. Like, it is a part of their health and you address it, you’re talking about it, you’re thinking about it. And I never really understood that as much until I was really taking care of people.
And I think it was also the same time when I personally developed, I think, more of not just an understanding medically, but sort of like an understanding in the empathy sphere that…you know, because when you’re a med student or you’re a resident, someone comes in and like, you know, they have anxiety, depression, and OCD, and bipolar disorder, you’re like, “Oh, my God, this is gonna be, like, so hard to figure this out.” And you’re just like…But we don’t do that with medical problems, so to speak, you know, and that’s a shame and that’s a problem, and that’s a problem in our training.
And it really took until I was having these relationships with my patients to really begin to appreciate what they’re going through. And I totally get what you said, our trainees are so comfortable saying, “All right. We’re gonna start insulin on her. We can give her this dose, this kind, we’re gonna up it by two units at this time. And because she’s on insulin, I’m gonna make sure she’s on this hypertension medication.” It is complex stuff. And you’re like, “What about depression?” They’re like, “I don’t know.” You’re like, “Can’t you just add some Zoloft?”
Dr. Miller: Right. I’ll refer to psychiatry.
Dr. Fox: Yeah. I mean, like, “Well, you don’t know how to prescribe Zoloft?” I mean, like it’s like the craziest thing in the world. It’s like 100 times easier than insulin, right? But that’s just how things…It’s getting better obviously, fortunately, because of people like you, but it’s just…traditionally was it was like, “Oh, no, that’s psychiatry.” It’s almost like when, you know, we always joke like, “Oh, no, that’s a woman,” right? Gynecology. She’s having a stroke. A gynecologist has to clear her, you know?
Dr. Miller: Right. No, it’s totally true. And I think, you know, the flip side that, I don’t say this at all to disparage our colleagues in mental health, but, you know, they can often say, “Oh, well, you wanna become pregnant or you are pregnant. We can’t manage this anymore.” And so I think so many people fall through that crack of that intersectionality where they don’t have someone that’s comfortable or they’re getting mixed messages or, you know, God forbid, they’re reading these headlines that, you know, SSRX, all these [inaudible 00:19:18] that’s just misinformed without a right comparison group. And I think all of these end up harming pregnant people. So I think this is something that, you know, I hope we can continue to dialogue it in our sphere, in our world, and then, you know, work with our mental health clinicians on the other side to make sure that their comfort level with pregnant people, you know, reaches our comfort level.
Dr. Fox: A hundred percent. So I wanna focus on two areas, almost backwards. I wanna start with the postpartum period because that is sort of the time where, for many people, they don’t have a history of mental health illness, or mental health diagnoses, or mental health treatments, and it may be their first experience with depression or anxiety, and to talk about that. And then we’ll talk about someone who does have that coming into pregnancy because I think the former is sort of the area that a lot of women who are pregnant are really concerned about. They’re like, “Wait. Is this gonna happen to me?” So, you know, how would you define…let’s take depression for now, even though obviously there’s anxiety. How would you find define the difference between or when it flips from just typical, standard, “God, it’s hard to have a baby, and life is tough, and I’m not sleeping well, and I’m just not feeling great,” to, “Hey, you have postpartum depression, you have a disease, you have an illness, you have a diagnosis?” Where does it change? Where does it cross the line?
Dr. Miller: I think ir’s such an important question. So when we talk about postpartum care and anticipatory guidance, you know, we talk a lot about this concept of baby blues. And I’ll sidebar for a moment. That terminology makes me a little bit insane. I find it so pejorative and it’s like if, for example, someone with angina, right, we call that angina. We don’t call it, like, ooh, it’s a little oopsie heart attack, or like a TIA isn’t ooh, a head-owie. It’s a diagnosis. And so…
Dr. Fox: Pre-stroke. Yeah.
Dr. Miller: Not to pathologize baby blues, but it’s just…I think language is so important and when we minimize symptoms or don’t kind of put it with any recognition behind it, I think it does minimize people’s attention to it. But that being said, you know, the data would suggest that 50% to 80% of women will experience this “baby blues,” which is feeling overwhelmed, tearful, crying but still being happy. And that usually resolves within two weeks postpartum. Differentiating that from postpartum depression, I think the two paths that we monitor, the two very characteristic features of depression are either having a depressed mood, feeling down, blue most days of the week, or what we call anhedonia, not enjoying day-to-day things.
And, again, that’s not just, you know, at 2:00 in the morning when you’re not enjoying getting out of bed and feeding your baby for the 800th time, but really not enjoying any part of your day most days of the week over the 2 prior weeks. And so one of the two of those needs to be present to meet diagnostic criteria for depression, and that’s not to say that there can’t be subclinical, or [inaudible 00:22:34], or you know, anxiety, like you mentioned, is such a huge component, but I think those are two things to keep in mind is, gosh, if you’re starting to feel like that, then it really is time to reach out.
Dr. Fox: Yeah. How common would that be? So you said like 50%, 80% will have something, but how common is it to reach the point that that’s happening that, you know, most days of the week you are either really feeling depressed or you don’t get enjoyment out of anything, really?
Dr. Miller: Yeah. It is not uncommon. So the data will suggest one out of every seven postpartum people will experience this. That’s not rare. You know? I mean, all of us, you know, even outside of the OB community, can think of seven pregnant people that we’ve known, one out of every seven will experience this. So despite…you know, it’s just shocking to me when you think about how common this is and yet how little training we get in obstetrics on [crosstalk 00:23:26.177].
Dr. Fox: Yeah. It’s more common than preeclampsia. It’s more common than diabetes of pregnancy. It’s on the order of the likelihood of a C-section. I mean, you’re talking, you know…and it is amazing because the other thing that’s so remarkable, you know, 1 in 7, 10%, 15%, you know, in that range, okay. But how many people have babies? Right? So close to 50% of the population on earth, right? Maybe not exactly 50%, but it’s up there. And so you’re thinking 10% to 15% of half of humans, right, are gonna experience this and have this. The numbers are astounding, how many people struggle with this. And I would say a lot of people, the diagnosis is delayed a long time, right? Why is that? Why do so many people suffer for so long before it gets recognized, or it never gets recognized, let’s say, [crosstalk 00:24:20.062]?
Dr. Miller: Whenever I give talks on this, I show this graph. I think it’s so eye-opening. So, you know, a lot of people in the health services world will conceptualize of mental health care as a care cascade. Like, each thing kind of depends on the thing that happens before. So to walk this out specifically, right, for a person with postpartum depression to be…ultimately, our goal is for her to have remission of her depressive symptoms, for that to all go away. She first has to be screened and then that screening has to be seen and acknowledged and a treatment recommendation made, and then she has to link to that treatment or begin that treatment and then even…you know, I mean, let’s not fool ourselves, our treatments are not fail-proof and so she has to respond to that treatment, right?
So each of those steps, if you march them down, the rate of remission for someone with perinatal depression, so these data are both during pregnancy and postpartum, kind of putting all together, the chance that any individual will achieve remission of her symptoms is 2% to 3%. And that’s contemporary analytic data from the United States, a good quality data. Can you imagine that we get something right 2% to 3% of the time? Like, that’s embarrassing. It’s terrible. And, I just, again, in other somatic diseases be like, “Oh, wow, you know, gosh, 2% to 3% of the time, we manage her preeclampsia appropriately.” We wouldn’t be allowed to be a field of medicine anymore. And so I think this should be really eye-opening that for something so common, we’ve got to get it right more often than this. It’s hard to get it right less often.
Dr. Fox: Where’s the ball being dropped mostly? Is it in the screening phase or is it in the treatment phase, would you say?
Dr. Miller: The biggest drop-offs are for screening and then for that initial recommendation of treatment. And so that, to me, is a call to action for us as OB providers, that’s in our wheelhouse. These are our patients and we need to be screening with a validated screen and we need to, when we see that screen, interpret it, dialogue around it, and recommend a treatment plan.
Dr. Fox: Yeah. And one of the amazing things is, you know, one of the ways we failed in America over the years as OB-GYNs is we would, you know, deliver these women and then they’d go home and we would see them six weeks later. And, you know, failure number one is they probably need to be seen, someone needs to be, you know, in touch with them in less than six weeks. And number two is at six weeks, even then, we weren’t asking about it and we weren’t really getting into it. And so I do believe that over the years, things have improved in terms of asking about it, screening about it at six weeks, but still, there’s the delay.
And what’s so fascinating, so in other systems, in other countries, and in other cultures, you know, postpartum care is much more intimate, right? There’s a lot more visits, home visits, connections, you know, all these things that happen. And I think what’s really fascinating is the people in the U.S. that, sort of, you know, took the ball that we dropped were the pediatricians and pediatricians said, “You know what? We’re seeing these moms like every day, every week. You know, in the first six weeks, we’ll see them eight times. And so, you know what? We’re gonna screen for postpartum depression even though technically our patient, so to speak, is the child, this is a family and this child’s, you know, birth mother is a critical part of this child’s health and we’re gonna make sure that she’s well.” And they started screening and they started picking it up, and God bless them. That’s awesome, right? Because I don’t see postpartum women two days after birth, and four days after birth, and a week after birth, and two weeks later. And if I did, that’d be great, but since I don’t, they do, and they’ve taken the mantle, and I think it’s just awesome.
Dr. Miller: Yeah. I think you’re totally right. It’s been great to have that, kind of, really be introduced and implemented into pediatric practice. I think I would imagine, and what I’ve heard from pediatric colleagues is it’s just when you’re going to screen, screening intrinsically by itself doesn’t help anybody. Screening with initiation of treatment linked to it is what’s gonna help. And most pediatricians aren’t comfortable with adult prescribing. And so making sure they have the right linkage to what that next step is and feel comfortable with that adult counsel. But yeah, I mean, it takes a village. And, you know, we can’t think about this in the absence of what’s happening now with COVID where it’s also not uncommon for family members to notice, “Hey, this is different. You’re acting different.” Or, “I’m concerned about you,” and encourage the postpartum person to reach out for help. But we don’t see that as much now because families aren’t flying in and there’s not, you know, this village around the postpartum person during the pandemic. So I think we need to pick that wall up and make sure that we’re kind of inserting ourselves as part of that village.
Dr. Fox: I hope you enjoyed part one of my discussion about postpartum and perinatal depression with Dr. Emily Miller. Make sure to check out part two 1 week from today. Have a great day.
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