Amber Cummings was in her second trimester and steeped in the months-long process of preparing for the winter arrival of her firstborn. As her body built the baby-to-be, her mind was under a steady barrage of pros and cons and purchase decisions associated with all the strange infrastructure surrounding the new addition – rocking chair, car seat, stroller and, of course, a crib.
The crib was on her mind on this particular day. Cummings happened to be at the office and happened to think about her baby pressing her face against the slats of whatever crib she chose, and breathing in too much carbon dioxide, and…. and she broke into tears, right there at work.
“I was just hysterical,” recalled Cummings.
It hadn’t been the first time.
“Going into the second trimester, I could not stop crying,” she said.
Fortunately, Cummings had somewhere to go for help – the same place she was going for her prenatal care: UCHealth University of Colorado Hospital. There, seven practices focused on bringing babies to the world share a common service dedicated to the mental and behavioral health needs of pregnant women and those who have recently delivered. It’s called the Promise Clinic.
Not-so-nice to meet you
Postpartum depression needs no introduction. It can be triggered when progesterone and estrogen levels crater after delivery, upsetting the delicate hormonal balance that keeps body and mind healthy. But the Promise Clinic also focuses on what you might call “prepartum depression.”
University of Colorado School of Medicine psychologist Bethany Ashby, PsyD, who is part of a team that sees about 300 new patients a year at the Promise Clinic, said it’s more common than people think. Its roots often lie in undiagnosed, pre-existing mental and behavioral health conditions that women manage to cope with on their own until the combination of prenatal hormone swings, sleep problems and the stress of life-change tips the balance, Ashby said.
That was the case for Cummings, now 29. She had always been the type to wash her hands a lot, to triple-check that the door was locked, to keep an eye on where she’d just walked to make sure she hadn’t dropped anything. Despite having dated her now-husband Chris since high school, she had been anxious enough about the idea of marriage to seek counseling. Now happily married and pregnant, she sought it again.
The Promise Clinic happens in standard OBGYN and other exam rooms at the Anschutz Outpatient Pavilion. Patients are typically referred through providers in the OB, Midwifery and Maternal Fetal Medicine practices, as well as the UCH Birth Center.
There is a lot of demand, Ashby said, for this program grew organically from its start about a decade ago. Judith Mikacich, MD, an OBGYN interested in women’s mental health, reached out to psychiatrist Cheryl Chessick, MD, who started seeing pregnant women and also working with medical residents, obstetricians and midwives on how to help them.
Mikacich and Chessick moved on; the program they started took root. The core team now consists of obstetrician Stephen Scott, MD; psychiatric-mental health nurse practitioner Cate Campisi, NP; nurse navigator Kristina Shillingford, RN; midwife Amy Nacht, CNM; psychologist Christine McDunn, PhD; and Ashby. CU School of Medicine Psychiatrist Lynne Fenton, MD, is helping out as they look to fill that role for the long-term. As is all too common with mental and behavioral health services, the societal need is greater than the financial means. Grants from the likes of the Walton Family Foundation help make the Promise Clinic possible, Scott said.
Patients take different paths depending on their cases. Someone worried about aspects of childbirth itself might be referred to Nacht, the midwife. Patients with severe mental health issues – bipolar disorder, schizophrenia and the like – may go straight to a psychiatrist. Amber Cummings worked mostly with Ashby, a psychologist. Depending on the case, patients come in anywhere from once a week to once a month (Cummings visited weekly).
Psychotherapy and pharma
The Promise Clinic has two main therapeutic levers at its disposal: psychotherapy and medication. Cummings and Ashby started with therapy.
“People ask me what therapy is like and what we do, and I don’t know how to describe it. I just know it works,” Cummings said. “We talked through things, and she helped me realize that some things were irrational without saying as much.”
While there was progress, Ashby suggested Cummings might also benefit from an antidepressant. At first, Cummings resisted. She didn’t like the idea of her baby also being on an antidepressant. It was a rational worry, Ashby said. For example, doctors avoid prescribing ADHD drugs – stimulants, typically – during pregnancy. With drugs for bipolar disorder, there may be risks later, associated with transferring the drug to the baby during breastfeeding, she added.
But antidepressants are considered safe, Ashby said, and there were other considerations. A mother with what seems like a manageable mental and behavioral health problem during pregnancy may go over the edge postpartum. Antidepressants can help stop that from happening. Also, Ashby said, “there are negative outcomes for babies associated with untreated depression,” including preterm delivery, low birthweight, and a propensity for their own mental health issues.
“The cost of treatment has to be weighed against the cost of non-treatment,” Ashby said.
Message to moms-to-be
Ashby didn’t push the antidepressant. Cummings at first wanted to wait until she delivered. But a month or so later, she agreed to try Zoloft. It helped. She remained on it through the Christmas Day birth of her baby girl, Elsie, and through the six months of postpartum care the Promise Clinic includes. After that, clinic staff helps steer new moms to community resources.
For Cummings, that community is far from metro Denver: Chris is starting his medical residency in North Carolina, where she will become a divinity student. It’s another stressful life change, this time to an unfamiliar part of the country with an infant and no family support. That she’s handling it without tears is a sign of the staying power of the Promise Clinic’s help, she said, and she hopes other moms-to-be take note.
“Even if there are people around you saying that it’s normal or fine or buck up or whatever, you should get the help you need,” Cummings said. “Don’t hesitate to get help, and be vocal about it. It’s too easy to brush it off like it’s normal.”