Lissa Miller, 31, has a history of mild depression and anxiety — the conditions run in her family. She used to manage her symptoms with exercise and meditation.
But two years ago, soon after Miller had her second child, the mood disorders rapidly progressed. She had intrusive thoughts of being a bad mother, a failure. A licensed social worker, she was reluctant to ask for help. She knew the system and feared she would lose her job or her kids would be taken away.
Her friends and family pushed for her to see a doctor, who recommended medication as the best route of treatment.
“I’m a pretty smart person,” said Miller, who lives in Parker. “Why was it so hard for me to get help?”
Miller, a vivacious woman who today is at a positive place with her mental health, is one of the every 10 women in Colorado who experience pregnancy-related depression — the most common complication of pregnancy, medical providers say. Nationwide, that number is one in seven. Stigma, fear and access to care often are barriers to receiving treatment. Public health officials and medical providers stress the importance of knowing the symptoms and early intevention.
“So often in life, ‘everything is great and we are so happy with our lives’ is the story we tell,” said Mandy Bakulski, manager of the Maternal Wellness and Early Childhood Section at the Colorado Department of Public Health and Environment. “We need to be encouraging moms and acknowledging that the experience is not as positive as it’s made out to be.”
‘They are not alone’
Each year, about one in five women in the U.S. experience some type of mental health condition, most often depression and anxiety, according to the U.S. Department of Health and Human Services. Women are more than twice as likely as men to develop an anxiety or depression disorder in their lifetime.
One of the top drivers of Colorado’s increasing rates of maternal mortality is mental health-related causes, Bakulski said, including suicide and substance-use overdose.
Between 2008 and 2013, the state recorded 145 pregnancy-associated deaths, according to the Department of Public Health and Environment. Of those, 40 were related to mental health conditions.
While the majority of mothers with mental health problems get better, extreme cases show the importance of addressing and treating mental illness early on, public health officials and medical providers say. In December 2016, a Highlands Ranch mother shot and killed her two young sons before taking her own life. Two months later, another mother in the community shot and killed her young daughter and then herself. Authorities later released that both mothers had a history of mental illness. One suffered from depression and bipolar disorder, the other from anxiety and substance use.
In Douglas County, 21 percent of women ages 18 to 44 said they had depression, according to data collected from 2013 to 2015 by Tri-County Health Department, which serves Douglas, Arapahoe and Adams counties. That falls right behind the Colorado average at 22.9 percent.
That number includes all cases of depression, which can be caused by a combination of biological, physiological and social factors. Often overlooked, pregnancy-related mood disorders are under the umbrella of mental illness, according to medical professionals in the perinatal field. The most common are depression, anxiety, post-traumatic stress disorder and obsessive-compulsive disorder. Symptoms may present themselves during or post-pregnancy, or following the loss of a baby.
“It’s not normal to feel that way, but it is common and a lot of women feel that way,” Bakulski said of pregnancy-related mood disorders. “We want moms to know that they are not alone.”
Stigma may cause under-reporting
Maria Ayers is the budgeter, planner, cook, driver.
“Taking care of ourselves is the last thing that’s on our mind,” the Roxborough resident said of being a mother. “You want to take care of everyone else.”
Ayers and her husband had their first daughter in 2008. They had a plan: Two years later, they would start trying for a second child. Then they had twins.
On one hand, Ayers was elated. They had a healthy boy and girl — one just over 6 pounds, one under 6 pounds. But Ayers had been working part-time and her husband was facing a potential layoff. Her parents and sisters live out of state.
She takes pride in caring for others and was reluctant to ask for help when she needed it most.
“Two-and-a-half or three months in I started feeling really out of sorts,” Ayers, 39, said. “It’s like you are seeing yourself live your life but you’re not really there for it.”
Ayers is one of several Douglas County mothers interviewed for this story who have experienced pregnancy-related depression or anxiety. Symptoms typically persist longer than two weeks and can include feelings of anger or irritability, lack of interest in the baby, feelings of guilt, or possible thoughts of harming the baby or oneself.
In 2014-16, 4.2 percent of Douglas County women who recently gave birth reported experiencing postpartum depression, according to Tri-County Health Department. That’s lower than the state average at 10.4 percent, but still a cause for concern among public health officials and healthcare providers.
“We think that is an underestimate because it’s a self-report,” Bakulski said. “Given the stigma and fear around disclosing symptoms, it’s likely some women don’t respond the way that they are actually feeling.”
Pregnancy-related mood disorders differ from the baby blues, which 50 percent to 85 percent of new mothers experience, according to Jenny Paul, licensed clinical psychologist and clinical director of the Healthy Expectations Perinatal Mental Health Program at Children’s Hospital Colorado, which provides resources for mothers during and post-pregnancy. Perinatal is a term used to describe the period before and after birth.
The baby blues are feelings of sadness or moodiness that occur in the week or two following birth. Typically, those feelings are sadness, insomnia, loss of appetite or irritability, and generally disappear in one to two weeks.
“A lot of times, women who are experiencing baby blues will not go on to experience postpartum depression or anxiety,” Paul said. “But many times they will.”
Every experience is different
As a licensed social worker, Miller worked with people in detox, abusive parents, neglected children, battered women. The profession, she said, left her with some post-tramautic stress, which she believes exacerbated her symptoms of pregnancy-related depression and anxiety.
A variety of factors, from family history to trauma to access to resources, play a role in pregnancy-related mood disorders and the mental health of women in general, medical professionals say. They emphasize that every experience is different.
“For some it’s a hormonal shift, for some it’s having a history of depression or anxiety, for some it’s ending breastfeeding,” Paul said. “We want to be really mindful about every person’s unique situation. Everyone really is bringing different cards to the table.”
Nationwide, family support systems have changed, Paul explained. Historically, new parents stayed in their hometowns, close to grandmas and grandpas, aunts and uncles.
“We had greater social support,” Paul said. “I think we are a very mobile society nationally these days, so often we find moms that are very isolated.”
Nikki Brooker, a mother of three in Highlands Ranch, has a similar outlook. She was living in Littleton when she had her first two children. Her mother had recently died, her immediate family lived out of state and none of her friends had kids. She felt isolated and overwhelmed so, with her husband and two kids, moved to Ohio, where her sister-in-law and mother-in-law live.
“People need support,” said Brooker, who moved to Highlands Ranch in 2007. “They need to know that they are not alone and that there are other people that are going through the same thing.”
Parenting in 2018 looks a lot different than in 2000, when Brooker had her first child, she said. Social media puts an immense amount of pressure on mothers to live up to a certain, often unattainable, lifestyle, Brooker said.
“I think it’s not necessarily Highlands Ranch or Douglas County, but our culture as a whole,” she said. “The narcissism of our society — that I have a great life and great kids and a great husband — instead of being real.”
A message of hope
At the state, county and local level, efforts to address the mental health of women are on the rise.
To receive federal funding, the state is required to periodically assess community needs through a process that involves community partners and stakeholders. Feedback gathered from women of reproductive ages in 2010 indicated maternal mental health as a top concern. Since then, pregnancy-related mood disorders have been one of the state’s “priority-focused areas,” Bakulski said.
In 2016, the state partnered with Postpartum Support International and implemented a public awareness campaign for pregnancy-related depression and anxiety. Tri-County Health Department quickly jumped on board.
“The time is now,” said Vicki Swarr, perinatal services nurse manager at Tri-County Health Department. “Women are experiencing this more so than anybody ever thought. They are not to blame.”
The goal is to educate families and healthcare providers on warning signs of the mood disorders. The campaign’s messaging is consistent: You are not alone, there is help, you can get better. The hope is that even if a mother can’t recognize her symptoms, a spouse, sister, brother, friend or doctor can.
“We know often that the support systems might notice something looks different before the women themselves are able to articulate how they are feeling,” Bakulski said.
The state is working to increase the number of providers who are trained to work with pregnant or postpartum women, and to strengthen the healthcare referral system to better connect new mothers to the appropriate services, whether that is a counselor or support group.
Oftentimes, cost and long waitlists are significant barriers to seeking treatment. Maternal mental health is not specified under the federal parity law, which requires health insurance plans to provide coverage for mental health treatment.
“In general,” Bakulski said, “we don’t have enough mental health providers to cover all of the mental health issues.”
Children’s Hospital Colorado is one of several health and advocacy organizations that hopes to change that.
In response to a growing demand across Douglas County for support groups and services for new mothers, the hospital expanded its Healthy Expectations Perinatal Mental Health Program to its south campus in Highlands Ranch, 1811 Plaza Drive. The program offers weekly support groups for mothers and their babies.
“We really want to have a prevention focus. It gives us an opportunity to provide support as early as possible,” Paul said. “We don’t want to wait until moms need intensive treatment.”
After witnessing the devastation caused by the death of the two Highlands Ranch mothers and their young children, Brooker knew a change had to be made in her community.
A year later, she started You Are Not Alone Mom 2 Mom (YANAM2M), a nonprofit organization for mothers in need of a safe space to connect. The group meets weekly at various locations around Highlands Ranch. Each new mom is offered a “support mom” who acts as a mentor and friend.
Brooker can confidently say her group has saved the life of one mother.
“When you feel connected,” she said, “it changes everything.”