E117 - How Does Pregnancy Affect Mental Health? (w/ Dr. Livia Martucci)

Dr Livia Martucci is a consultant in perinatal psychiatry, and is the clinical lead for perinatal services in South London and Maudsley NHS Foundation Trust. She is experienced in assessment and management of many common and complex mental health problems including anxiety, panic, OCD, depression and other disorders such as Bipolar Disorder as well as psychotic illnesses, both in the perinatal period and more generally in men and women, and has experience of partners/fathers with antenatal and postnatal anxiety or depression. She has worked with mother and infant dyads providing parent infant psychotherapy.

She is currently chair of the faculty of perinatal psychiatry for the Royal College of Psychiatrists. 

Interviewed by Dr. Alex Curmi. Dr. Alex is a consultant psychiatrist and a UKCP registered psychotherapist in-training.

If you would like to invite Alex to speak at your organisation please email alexcurmitherapy@gmail.com with "Speaking Enquiry" in the subject line.

Alex is not currently taking on new psychotherapy clients, if you are interested in working with Alex for focused behaviour change coaching , you can email - alexcurmitherapy@gmail.com with "Coaching" in the subject line.

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Disclaimer: None of the information discussed in this podcast is intended as individual medical advice, changes to medication plans should always be made via discussion with the prescriber.  Abrupt withdrawal of medication can cause serious adverse effects. 

Transcript

Welcome back. Today we're gonna discuss something we haven't previously discussed on the podcast, and that is the specialty of perinatal psychiatry. As some people may know, pregnancy and the period immediately after pregnancy are usually considered a more high risk time for the development or relapse of mental health conditions.

Today I'm very pleased to start this conversation with Dr. Olivia Marucci. Dr. Marucci is the chair of the Royal College of Psychiatry's, faculty of Perinatal Psychiatry. She has extensive experience in the assessment and management of common and more complex mental health conditions in pregnancy and immediately post-pregnancy, and she's the clinical lead for perinatal services in the South London and mos the NHS Foundation Trust.

Today we discuss what perinatal psychiatry is and how that differs from general psychiatry, why the perinatal period is considered to be a high risk time for mental health. A little bit about medication, when that can be useful in the perinatal period, and how to mitigate the risks associated with [00:01:00] psychiatric medication in this time.

What people can do besides medication to manage their mental health as well as possible in the perinatal period. The effects of hormones on mental health. Not just the natural hormone fluctuations of pregnancy, but also the hormonal effects of things like the oral contraceptive pill IVF and egg freezing procedures.

We discussed to what extent pregnancy and motherhood are affected by cultural constructs that we create around them, particularly more modern cultural constructs in the West. What parents should be aware of psychologically speaking before having children and much more. This is The Thinking Mind, a podcast all about psychiatry, psychology, psychotherapy, and self-development.

As always, if you like it, do give us a rating, leave a review, follow, like, or subscribe on whatever platform you listen to or watch. This really helps new people to find the podcast. If you'd be interested in supporting the podcast further, check out some of the links to the description. And now here's today's podcast with Dr.

Olivia Marucci.[00:02:00] 

Dr. Marucci, thank you so much for joining me. Just thank you for inviting me. Today we're gonna talk about perinatal psychiatry, something we haven't discussed much before on the podcast, but we've been getting more requests from our listeners to talk about women's health and women's mental health.

Obviously, a very important topic. Maybe you could take us through what, what is perinatal psychiatry, how is it different from general psychiatry? Perinatal psychiatry is the care of mothers and babies or [00:03:00] birthing people and, and the relationship between a baby and the primary caregiver from ideally.

Ahead of conception to the whole length of the pregnancy and then the beginning of the baby's life. So the first postnatal year, and in some cases up to the end of the second postnatal year. Is it fair to say that's considered the high risk time for someone's mental health? Yes, it can be for specific people who have a certain diagnosis.

There certainly is an increased risk of relapse during the perinatal period, but we also must remember that generally speaking, pregnancy is, uh, major test for both the. Body and the mind, and that means that any potential for manifestation of illness may well materialize itself. [00:04:00] During this time, whether we are talking about a psychiatric illness or a physical one, so Right.

So it's a period of high stress. If there's any vulnerability, that's the time when something like that could come out. Yes. I think it's fair to say. Mm-hmm. And do we have under any understanding why that is? Um, is it, for example, anything related to the hormones around pregnancy and Beth that might be having an effect to something else?

We, we certainly know that hormones change significantly in, in pregnancy, and indeed they change during the menstrual cycle. And if we are talking about psychiatric disorders, we know that. Women's mood can change even during a normal menstrual cycle because of the changes in the hormonal pattern during this time and in pregnancy.

Of course, there are very significant hormonal changes that can affect the mood in various. [00:05:00] Ways, and, and of course they can sometimes be associated with increased stability. That's also been known to happen. Some people describe feeling very calm and. Controlled and generally very even minded in pregnancy.

But it can also very much contribute to people feeling more distressed, more irritable, more easily overwhelmed. And the other thing to remember is. That this doesn't exactly resolve itself. When pregnancy ends after delivery, there's a huge drop in two hormones that had been increasing steadily during pregnancy.

Progesterone sterol tend to drop massively in the first 48 hours, more or less following delivery. And that impacts on the mood of the vast majority of people who [00:06:00] have experience of this as something commonly known as Baby Blues, which is a brief, short-lived period of increased emotional liability. And then following that it takes a while for the body to recover a normal rhythm.

And of course, when someone decides to breastfeed, that too means other hormonal changes. That can impact on the mood as well. Mm-hmm. So would it be fair to say that in this perinatal postnatal period that there is an increased risk of pretty much any mental health condition, whether it be anxiety, depression, bipolar disorder, psychosis.

Are those all at increased risk or is there any particular disorders which stand out in this regard? Well, there are. I think it's fair to say that any preexisting condition can be exacerbated, but we are also very aware that there are specific conditions. [00:07:00] That carry a particular risk. For example, if someone has a diagnosis of bipolar disorder type one, which means somebody who has had many episodes or depressive episodes with.

Psychotic symptoms for that particular group. We know that there is a much increased risk of developing a severe complication of pregnancy called postpartum psychosis, which can occur in the general population. It's, it's a complication of pregnancy, but in the general population it is. Uncommon, it falls between one and two people in a thousand.

But for people with a bipolar disorder and possibly people with a history in the family of bipolar disorder or or postpartum psychosis, the risk can go as high as 60%. So it's, it's an hugely increased risk. And that is one of the reasons [00:08:00] why perinatal services had their onset, because we realized. That there was a very defined window of predictable risk that required a great deal of monitoring and intervention and joint working with maternity and other allied professionals, and, and that meant that general psychiatric services would be too busy and overwhelmed to provide that.

So that being the case, if someone has a preexisting condition, be it bipolar or depression or psychosis, they're stable, but they're planning on having children or they become pregnant, what do you, what do you think are the steps they should take? First of all, it's very important to remember because this is something that sometimes people ask that the vast majority of people who decide to become parents or find that they will become parents are very happy that they made that [00:09:00] decision.

And they are very happy that they decided to take that step and become parents, even if that meant an increased risk of having some symptoms of become or becoming unwell for a while. One thing that people can do is if they have a mental health condition and they wonder what that might mean if they become pregnant, is to seek the advice of.

A perinatal psychiatrist in a preconception stage. So it's very difficult to give generalized advice, and I'm sure a lot of my colleagues that have spoken here may have said the same thing. We, yes, have guidelines, but I. In truth, we can only give advice to one person for that person. So what needs to happen is a detailed in-depth assessment and following that we can give some sense to that person of what their risks are and what [00:10:00] their care should look like, and if part of their care is medication, what that might mean and what that will.

Look like in terms of their treatment because they may need to make some decisions about either changing it or they might choose to do that or choose to stop the medication. They will need to know what that could cause. Of course, I've focused on bipolar disorder, but there are many other, there are other psychiatric conditions are.

Equally as important, especially during this time, that can cause a great deal of disruption in people's lives. Yes. And you mentioned medication and I can imagine a lot of people might be, feel a bit apprehensive about taking medication, the perinatal period. What are the, the, like, the steps or safeguards that perinatal psychiatrists take around medication to make sure it's kind of safe and and appropriate?

The first important thing to [00:11:00] remember is that medication is very often part of a wider picture, part of a wider care plan, and it's not a solo entity as such. Sometimes it's necessary and unavoidable. If someone wants to stay well, they need to take their psychiatric medication in the same way as they might need to take some metformin, for instance.

If they don't, their sugar levels will be really too altered. If they don't take their psychiatric medication, their psychiatric symptoms will play havoc with them. But, but. The important things to think about is first of all, to feel very, to feel, how can I put it, to feel comfortable with the fact that it is uncomfortable.

It's not an easy decision to take medication, in pregnancy, whatever that medication might be. A lot of people have doubts and questions about it. And it's [00:12:00] always important to think about a number of things. For example, this should include which medications have been effective before, which haven't been effective.

What happened when someone tried to stop their medication? Did they relapse? Did they stay well? Have they ever even tried? What happened when they changed their dose? What side effects could they tolerate and which were not? Tolerable and to try and balance between the risks of their illness and, uh.

Risks connected to the medication. Sometimes when people become unwell and they are unwell, their behavior really changes. They don't sleep anymore, they don't eat as well, they don't look after themselves. Sometimes it can lead to extreme behaviors as we know that can be either risk taking or even self-destructive behavior, and that arguably may cause a greater risk to their pregnancy than than the medication itself.[00:13:00] 

Sometimes what also happens is if people stop their regular medication and they become more unwell, they may need a higher dose or more than one medication to treat their symptoms. So sometimes it can backfire, but a lot of that is based on previous experience. Any, and one thing that we know because it's been studied more extensively now, is that stress causes changes to the HPA.

Access, which regulates our hormonal functioning and the functioning of substances like cortisol, which can be filtered through the placenta. But when there is sustained, increased ongoing stress. That filter isn't as efficient and that changes the environment in which the fetus develops. And it can have implications as well on fetal development, both cognitive emotional and behavioral [00:14:00] modifications, and also some physical health related modifications.

So it's not an easy decision because there are so many factors to consider. And the other very important thing is that it's not easy to talk to someone. As you can imagine and say to them that perhaps their symptoms could be causing some damage to their baby because otherwise they will inevitably feel between a rock and a hard place.

So it's about being very clear about information about medication and helping people to be, feel supported in the decision that they make, and be as positive and as optimistic as possible on on their recovery. And the fact that they can get better. And do we have a clear understanding of which medications are like lower risk to take in pregnancy?

Do, do we have a clear understanding of which medications are reasonable to prescribe in such a situation? A good number of psychiatric [00:15:00] medications have been, especially the ones that have been around for a long time, are well known and they are largely quite benign. So for example, many antidepressants like the.

Selective sero injury uptake inhibitors. SSRIs like fluoxetine, citalopram are all very well known and well studied. We know that so far as we know, there aren't any significant risks that would stop us from prescribing them. Of course, I'm, I am not going to go into the details of each of them. It's, it's very difficult to say that something's.

Can never, ever know whether some absolutely minor in remote obscure risk that is so rare, hasn't been picked up in any research, but based on a very large number of studies that have been done, that have been pulled together, [00:16:00] we think that these are medications that are effective, generally speaking, and don't carry a high amount of risk.

Other antidepressants as well, like mirtazapine are. Well known and well used, and many of the others can also be prescribed in pregnancy. Same for antipsychotics. These are all medications that can have side effects are quite significant and unpleasant. So let's not forget, I. That doesn't change because someone is pregnant, so they always have to be prescribed with a grain of salt when they're absolutely necessary.

But sometimes they are necessary and they can be prescribed and they need to be monitored. Sometimes there needs to be some additional monitoring, for example, for medications that we know. Induced metabolic changes, we may need to work together with the obstetricians to think about checking for gestational diabetes in some cases.

That's one example. We may well [00:17:00] need to be very careful with medications such as lithium for bipolar disorder, because we need to monitor the levels. Very closely during pregnancy, and we need to make sure that they remain in a very narrow window because we know what happens with excessive amount of lithium.

It's never really a good thing in general, and even more so during pregnancy. And there need to be more monitoring of other functions like kidney function, thyroid function, that that need to be put in place. There are some medications that we know are. Dangers in pregnancy because they are so-called teratogens, which means that they increase the risk of congenital malformations such as valproate, sodium valproate, carbamazepine as well.

These medications would ideally not be prescribed to women of childbearing age. Which is not always possible. And [00:18:00] of course for some people who have epilepsy, they need to be prescribed because they're also antiepileptic medications. They're anticonvulsants, but, but we do know how dangerous they can be in the psychiatric population.

There are more question marks as to whether these should be prescribed. Yeah, it's so important. Always take into account the risks and the benefits, which is something we talk about. A lot on the podcast, particularly when it comes to adults, of course, because so often in the general adult population, people are just prescribed the medication and left on it for so long.

And I think one of the issues I have with long-term prescribing of psychiatric medications is people aren't encouraged themselves to look at, Hey, what are the benefits of the medication? What are the side effects? What are the downsides that I'm experiencing? They don't check in with themselves and unfortunately, often gps don't necessarily check in with their patients.

[00:19:00] Hey, you've been on this SSRI antidepressant medication for five years. Is it still working? Is it having a benefit? Should you still be on it? Should we be thinking about coming off the medication or trying something else? But I guess one of the advantages of the perinatal period is because there's so much more surveillance and and careful monitoring.

You actually take these things into account and you actually take medication based decisions very, very seriously. It sounds like on a very careful individual analysis. Yes. It's, I suppose that it can be looked at even more widely, perhaps, or at least that's how we often look at it. The medication can be a central issue, of course.

It is a time of such change in somebody's life in so many ways that inevitably people will think about reviewing their care and their treatment, including, of course, the medications they [00:20:00] take. But sometimes people will also review their lifestyle, their relationship, even their, their relat, sorry, that they have even sold.

It can at times be a transformative experience and improving lifestyle often makes very positive changes to mental state. And perhaps this was the motivation that they needed because we all know what a powerful, what a powerful motivator becoming a parent can be. So. Sometimes it even happens in some cases for some people, that their treatment changes enormously.

Even their medication plan can change and reduce enormously because they have a whole new approach to their own health and can do so much more to keep well. And what, what do you think outside of medication, what are the main things you would recommend to people to maintain or even to improve their mental health?

Again, it. Will [00:21:00] be fairly individual and it will depend on how that person's life already is, but certainly ensuring if we are talking about someone who already has a diagnosis of mental illness, looking after themselves, making sure that they're actively involved in their care. Is really important.

Learning about their mental illness is also very important. Trying to understand what their triggers are, what makes them feel better, what makes them feel worse? Think about I. All the things that they can do to be better. Those are things that are very important. They, again, may include things that have got nothing to do with drugs.

It may be about social contact. It may be about workforce inclusion, when that's possible. It may be about stopping some habits that are not very helpful, like taking strict drugs [00:22:00] or drinking too much alcohol or. Staying up really late at night every night and not giving themselves enough time to sleep, not eating very well, all these things can contribute.

Loneliness can really play a big part. So there are many things that I think people can do to try and feel better and be as healthy as they. Can be really. So this I think, is true in general, not just for people who are thinking about becoming pregnant, but it's especially important for anyone who is thinking about becoming pregnant, becoming a parent, because.

Once they are parents, of course, something that most people would say is wonderful and and magical, but equally it's really hard work and can be relentless and it can be very stressful as well. So that won't be a time where people can really get a lot of rest and relaxation and that they'll be kept on their [00:23:00] toes.

Absolutely. Yes. And something else I wanted to ask about is. We can hypothesize that at least some of the stress of pregnancy and the postnatal period is likely due to hormonal changes. And of course, pregnancy itself isn't the only situation where women might encounter hormonal changes. They might encounter them if they take the oral contraceptive pill for a long time.

If they do something like IVF. If they do something like an egg freezing procedure, which requires them to take a fairly large amount of hormones up until the point of the procedure. To what extent do we understand the mental health impact of taking these kinds of hormones? Is it something that is, remains to be studied?

Is it still kind of an open scientific question? What do we know about this? I think that there's more understanding, but if again. These are very variable depending on the person, so some people may well not find that it affects them [00:24:00] deeply, and other people will feel really changed when their hormonal levels change.

We know that's something that in itself has got great variability. The other thing to add is that some of these experience also carry a big emotional. Side to them. So for example, IBF is rarely stress free, if ever. It often comes as part of a longer journey of difficulties trying to conceive. So there's so much riding on it as well as of course, all the impacts that the physical treatments, the hormones will have.

I'm not sure that it is always easy to extricate the two from one another. Again, for some people they might really tell you, I know that if I take the hormones, I become like this because that's, I know. That's how I can feel that there's something that happens to me that is not my usual self and that it only happens [00:25:00] when I'm having these treatments, et cetera, that largely people will find that it's a mix of the two.

Do you think similar to pregnancy. It's important to warn people ahead of these procedures. Hey, you know, you're gonna be prescribed some hormones. They may have no effect, but if you have a pre-existing condition, it may contribute to a relapse of that condition. Do you think it's reasonable to, to issue that warning to people?

Because I, I wonder if it is even issued enough. I think. I think it is reasonable. I think that many IDF centers will do some screening, whether they are private or, or NHS centers. They will do some screening to ensure that they're not leaving out anything that. Could be important, including whether somebody has got a preexisting psychiatric condition.

That's really important during this time. Some IVF [00:26:00] centers can also refer ahead of starting the treatment to a perinatal service to make sure that there is an assessment and to make sure that person's treatment is well thought through. Also from the psychiatric point of view, and they probably do it with other.

Specialist centers as well, like specialist services as well if, if somebody has other conditions that are not psychiatric. But yes, it's certainly important and information needs to be given because these are well known side effects also. Some treatments, so people can't have them, can't, should, would not be given an informed consent if they weren't counseled about this side of things.

Yes. And I also wonder, not I, I wonder about this not just in with regards to egg freezing or IVF, but even something very commonly prescribed, like the oral contraceptive pill. We've been talking a lot about antidepressants on the podcast. [00:27:00] There seems to be this gap between commonly reported anecdotal side effects of antidepressants versus what's officially sort of published in our literature and what we're warned about in guidelines.

And I wonder if there's the same gap when it comes to oral contraceptives. So as far as I know officially, it's never really discussed that oral contraceptives can contribute to things like anxiety, depression, or low moods. Anecdotally, that seems to be a different picture in terms of ma, many sort of people I've spoken to, patients, people in my personal life.

Would report that taking oral contraceptives for like long periods of time can contribute to feelings of anxiety, tension, low mood at times. Is this gap something you're aware of when it comes to oral contraceptives? And I appreciate you might not really be in a position to comment on this, but if you are, is this something you're aware of?

It's very variable. I think my impression, it seems to be [00:28:00] widely known that this could. Happen. And, uh, I wonder whether, depending on the prescriber, sometimes it's talked about, sometimes they are prescribed and they actually help people's mood become more even hormonal contraceptive. So it's very difficult to predict a very variable.

But my impression, I don't, uh, I, I don't usually prescribe contraceptives myself. That's often something that. GPS can do and women usually trust their gps to help them with those decisions. But I do check with women after they've had their babies that they have thought about a contraceptive plan, and they often talk quite knowledgeably about the impact of various different contraceptives on, on, on them, and if it ever comes up, of course I will also share with them that they need to think about these emotional implications, but.

It certainly we know that it is written in the, [00:29:00] uh, medication, little medication instructions that people get. It's, it's not necessarily something that is kept from people as such, but they maybe it's not always emphasized as much as it should be, or maybe people didn't anticipate it, didn't expect it, and they feel surprised that it's having this much of an impact on their mood.

I think it be interesting to talk a little bit about the. Impact of culture on pregnancy and motherhood. Obviously culture, cultural constructs, we make, you know, impacts almost every aspect of our lives and I think it really impacts, you know, pregnancy, motherhood. To what extent do you think, you know, in the west, we're, we're getting this wrong at the moment, are there any cultural constructs about pregnancy and motherhood that are unhelpful?

I mean, one thing I'm aware of is there's this in the West at the moment, there's almost this like. Ambivalence towards motherhood. That motherhood obviously is this wonderful thing, but at [00:30:00] the same time, there's this idea that motherhood is somehow taking away from women's independence or their ability to have their own power in society.

Do you think there's something important culturally that we're getting wrong about motherhood in the west? Should we be looking at other cultures and seeing how they're doing things? Cultural constructs around, I suppose, around pregnancy and motherhood has been around since. Probably the doll of humanity and for sure they've been hugely idealized.

And I think that more recently there are more voices that talk exactly as you say about. The possibility of ambivalence or even regret about the, the hard aspects of parenthood and society keeps changing and in the West as much as everywhere else, but society keeps changing. The role of women in society has changed enormously in the past.

[00:31:00] Probably a hundred years, maybe even less. There's much, much more expectation and desire that women will participate in the workforce, that they will build their careers, and inevitably pregnancy and motherhood are a break in a way from. That, that side of things. So I think we're still learning to integrate the two in a way, so sometimes more successfully than others.

Sometimes there's actual social injustice and people find themselves having to choose. I. Between the two money problems are really significant. So the cost of childcare, the, the stress of, of organizing it, all these things are so, it can feel so difficult that it can even discourage sometimes people from making that decision.

And also there is, it seems. There seems to be a new narrative developing that [00:32:00] in a way, parenthood will take away from one's own self-actualization, as it were. So if I have a child, I will have to give up my, I don't know. Traveling on weekends and museums and theater and friends and all that will have to be pushed aside.

Whereas before it was kind of not questioned and people just moved from one step of life to the other. And now we are more in a position where we can make choices as it were. So inevitably, sometimes when you can make a choice, the question will arise. Whether that's. The choice you want to make, and then that's just how it is.

But the other narrative that's more universal and official and longstanding is that it is the positive one around motherhood. So that pregnancy. Should be an excellent, wonderful experience, and [00:33:00] that delivery should be, again, a meaningful and wonderful experience that all mothers will find breastfeeding easy, and that there will be an instant influx of love for their baby, and that overall it will be overwhelmingly.

Wonderful and easy, but the reality is that none of it is easy and that pregnancy is, as we've said at the beginning, it's a big test for the body and the mind and to varying degrees. It can be, it can be difficult. It can be difficult medically, and it can be difficult emotionally, even if people. Are happy of their decision.

They want to be pregnant, they want to have a baby, but it doesn't mean that they will automatically enjoy the physicality of being pregnant as a result, and in my work, I have [00:34:00] encountered a lot of people who actually felt rather troubled by this, by realized by the fact that they realized they didn't, it wasn't the.

Wonderful, uh, sensation they imagined it would be. And similarly for delivery, there is a, a huge pressure and emphasis on how delivery should be and how people should want it to be. It is very easy for people to associate it with almost a concern that they could fail. If the delivery doesn't come easy, that it is somehow something they haven't done well, even though the only real good outcome of a delivery is that there is a life and well.

And alive and well mother at the end of that process. But, but it is very easy for people to feel that if, say [00:35:00] they needed some help during the delivery. Sometimes even just pain relief. Sometimes they required an obstetric intervention. Sometimes they needed a cesarean. That's somehow something they haven't done.

Well, that that can cause great distress and can actually contribute to people then becoming depressed afterwards. And similarly with breastfeeding, we all know how important breastfeeding can be and how valuable it is of course, and that whenever possible it should be encouraged. But it's not always the the optimal solution for each and every.

Mother and baby, it is very difficult sometimes for people to accept that they may need to think of other strategies and they feel a terrible sense of having let their baby down and themselves down. So these, these cultural constructs. Exist for a reason, because of course there is [00:36:00] something wonderful about being pregnant and about giving birth to a baby and about feeding one's baby, but it has been translated into a mantra that is very difficult sometimes to, to challenge when things feel a little bit different.

Yeah. I suppose a, a cultural construct like posits an ideal. But an ideal can quickly become an expectation. An expectation can become like a sense of obligation. I really do worry that there's a lot of pressure on young women nowadays that young women, implicitly and explicitly through societal messaging, are kind of expected to do it all.

They're expected to be high powered career women and mothers, and I don't think. It's adequately explained to young women how new this all is, how this is actually kind of a problem of modernity to have all of these choices. Then simultaneously, there's also a lot of, I think, [00:37:00] societal messaging through social media and other means that, you know, life can be optimal and easy and look at how great other people are doing.

Look at how great. So-and-so's pregnancy went and look how, how smooth her delivery went and things are going really great for her. And then that becomes another expectation and obligation. And I really do think something like more traditional that might be useful to recommunicate to, to younger women might be like, Hey, pregnancy is a really big deal.

It's tough. I think people understood that more, let's say a hundred years ago. Because of something as simple as like infant mortality being higher. You know, just understanding that, you know, pregnancy is a big deal. So it's almost by virtue of things getting in many ways easier and safer, we have fallen into a full sense of security and therefore we think pregnancy should just be this kind of easy thing that is without problems.

And then as you [00:38:00] say, when people then become pregnant and they say, oh, this is actually really tough. They feel the sense of failure and that can contribute to stress and resting mental health. And you know, someone's expectations are so important. Someone's expectations are so important because they inform how someone perceives their situation.

If someone goes in to something like pregnancy with the expectation that it's going to be hard, then they can handle it better 'cause they don't feel as though they've failed. But. If they go into it with the expectation that it's easy, then you know, any problem, as you say, gives them the impression that there's something wrong with them.

Something like that. That's very much the case. Yes, I think it's very well said. It's very easy to forget how unsafe it used to be. We, we know that even today it can lead to terrible problems that not every pregnancy has a positive outcome. Tragically, but for sure, [00:39:00] because we live in, in a world that's been in, in some ways more sheltered and safer than it perhaps had been in the past, it is harder for us to think of these threats as anything other than exceptional.

Whereas in the past, it people didn't know if they were going to have a boy or a girl. They had no idea if their baby. Was going to be healthy. They didn't know they had diabetes or high blood pressure or any of these things. So, and they certainly didn't know that they could develop a depression or a postpartum psychosis or an anxiety disorder.

So all of these things were. A jump into the unknown, whereas now that we know more and we can prepare more, and perhaps we can control a little bit more, that sometimes makes us feel as though we can bypass all of these problems and we [00:40:00] can't, but we, but we can monitor for them and we can optimize things whenever possible so that we reduce their impact.

Absolutely. And again, I think the same is. True for just, you know, general adults that we have fallen. Because in some ways, in some respects, life is so much easier. We then fall into the trap of thinking life is easy, and then when life gets inevitably difficult, it makes it all, it makes the pain of that somehow all the worse.

And I almost think people should just get a post-it note and put it on their computer and just write. Life is hard just to remind themselves that. Actually, none of this is supposed to be easy. Um, thinking more less about pregnancy and more moving on to early parented infancy, what do you think mothers and fathers should be aware of psychologically before having young children, what would you want, you know, expecting mothers and fathers to know [00:41:00] about, about Early parenthood?

That's a very good question. I suppose that in a way. Becoming apparent, especially the first time, is uncharted territory for each person that goes through it. So to some extent, it will always be surprising because it will be a little bit different for every person. Who, who goes through it. One thing I will say for sure is that again, the expectation that it should all feel wonderful.

Maybe an exaggeration. There will certainly be many wonderful. Moments, but equally, the bond with a baby is a little bit like falling in love for some people. It is in an instant across a room at first sight. It does happen. Really, it does. But for a lot of people it kind of grows steadily and slowly. And one day you turn around and you realize that's how you feel.[00:42:00] 

So in some ways. It's not, it's not completely reasonable to expect that everybody will have an instant, enormous connection. Some people do. They certainly do, and some people feel it growing a little bit more slowly and both things are fine. But sometimes parents do worry that immediate rush hasn't come.

And what does it mean? And that's very important. And also to remember parental love in some ways. He's an anxious love. It's very difficult to have a baby and not feel worried for them, and not worried that, am I doing it right? Am I, is this milk too hot? Is the bath too cold? Is the room too dry? Is this blanket too thick?

What is this gonna be? Okay? It's very easy to, to feel a bit worried about everything we do for our baby. I suppose this is particularly tough for the more [00:43:00] perfectionist people out there. You know, I think a lot of the people that listen to this podcast, they listen because they're interested in their mental health and what they can do to improve it.

So they might lie a little bit more on the perfectionistic side of the personality spectrum. And I imagine early parenthood is particularly tough on perfectionists 'cause there's this, this. This desire to get it 100% right, but of course you're not gonna get it a hundred percent right because it's just so, so tough.

Absolutely. And um, because it is already a time that can be an anxious time for people who are especially driven to, that it can make them feel even more intensely. Anxious. One thing to remember is that the, there has been a lot of the work done and a lot of thought given to what really is important and the concept that was proposed some decades ago was that of the good enough.

Parent. [00:44:00] Uh, so what babies really need is not a perfect, it's not a perfect parent who doesn't exist. They need someone who's good enough. Someone who sometimes will be a bit late 'cause won't hear them cry straight away, or will need to reheat the milk a little bit or is. That's what's happening, or will need to go to the bathroom or have a shower or whatever it is, or won't understand straight away what's wrong.

But life is full of these little breaks and repairs, and that's part of the experience of growing up, realizing that the world is an imperfect. Imperfect place, and it's very easy for parents to forget that and try to be ever present and completely consistent. Another emotion that is extremely common in parenthood, especially early parenthood, this guilt for getting anything even a little bit [00:45:00] wrong.

And it is very easy to get very caught into that guilt. And it is important to try and learn from things that didn't go well, but keep that recurring emotion at at bay because it takes space away from other more. Engaged emotions. And to what extent do you think it's important if someone recognizes they have some kinds of psychological difficulties or issues they're planning on having children in the, in the short to medium term.

To what extent do you think it's important for someone to try and their best to resolve their psychological issues or difficulties before having children? Well, I think sometimes psychological difficulties can be chronic. They're not. They're not something that is easily resolved in a brief time. I think it helps people.

To, well to start with, if somebody is wondering about that, like acknowledging and [00:46:00] understanding their psychological difficulties is a big part of it. I think it might be too much to expect of oneself to ourselves to want to resolve things before even planning to have a family. And also sometimes babies just happened.

I think about 40% of pregnancies are not planned, but. I think both for the purpose of becoming parents, but also for that of one's own wellbeing. Doing what they can to understand what is happening to their mind is really helpful. And then once the pregnancy come or baby comes thinking, trying to get help to think in a calm and reason way as much as possible, how their difficulties could impact on, on them as a parent is probably very helpful.

And when we were discussing offline, you mentioned [00:47:00] this concept of ghosts in the nursery, which is quite fascinating. Could you unpack that a little bit for us? What does this mean? So, yeah, so ghosts in the nursery is actually a paper that was written in the seventies by By an American who did a lot of parent.

Work, and it is the concept that the way that we have been parented and our own early attachment style will come into play when we ourselves become parent. And what that means is that the experience of having a baby or looking after a baby, both for the mother and the father, of course, for. The parents will put us back in touch with that part of ourselves.

That has been, that is still there, of course, but that we have kind of grown out of and built many [00:48:00] sophisticated layers over. And if our early experience was a very difficult one, if people have had a difficult early childhood, they might find. That they see some of that in, in their baby and in their experience of being parents.

So sometimes they can feel very overwhelmed by looking after their baby. They might find that it is very difficult to help babies regulate their emotions because they themselves can feel very dysregulated by that. Sometimes people can feel even a bit, uh, they can feel somewhat persecuted. By by, by their baby, and can struggle with feeling bonded to them because it feels almost as a threat perhaps, because that's how they themselves were perceived at the time.

So it can really bring back these older psychological dynamics. Yes, it can bring back. That's what it means. So the ghosts of our own early experience [00:49:00] can return to. Haunt us when it's our turn to do it. Sometimes in a good way, sometimes in, in a, in a painful way. And that's something that's very crucial to people's experience.

And again, probably not something that someone can, you know, resolve entirely, but just good to be aware of going in that, hey, you know, when you have children, it can bring back these older dynamics. Just to be aware of that going in. Maybe plan for it, maybe to do some things around that that could be speaking to someone professional or even just talking to family and friends about it.

Again, there seems to be a theme of just understanding that it's going to be hard and preparing for it rather than sort of walking in with your eyes closed. Yes, it definitely can be useful, and for some people, these are the conversations that they will have with their clinicians, especially if they are under the care of AAL service.

This is one [00:50:00] of the conversations that. Will happen when it's appropriate. One of the reasons why that's so important is that of course it will impact on the relationship with their baby, and in turn, it may impact on a baby's emotional development, how available their primary caregiver can be to them from an emotional level.

So what we are aiming for is to optimize the. Health of the mother and recognize, especially as we move forward, how much of that comes from having the involvement and participation and good health also of the partner when there is one or, and or family? So that the health of the baby can also be optimized and that the relationship can function well.

I suppose in answer to an earlier question that one thing that perinatal services do that is [00:51:00] possibly unique to them is that we focus with equal attention. On maternal mental health and infant health and the health of the relationship as three distinct area of, of equal interest. Yes, absolutely. We're out of time, but Dr.

Martucci, thank you so much for joining me today. Thank you for helping to discuss some of these very important topics. I'm sure our listeners will get a lot out of it. Thank you very much for coming today. Thank you for inviting me.