Q&A with Dr. Sharon Dekel: Understanding Postpartum PTSD

Sharon Dekel, PhD, is a licensed psychologist who conducts research in the Post-traumatic Stress Disorder Research Laboratory at Massachusetts General Hospital. Her work focuses on the postpartum mental health challenges faced by mothers. Dr. Dekel received the 2018 Susan A. Hickman Memorial Research Award from Postpartum Support International (PSI), the largest national organization for maternal mental health, for her novel study on the prevention of maternal psychopathology with the use of intranasal oxytocin. In this Q&A, she discusses that work.

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Q: What is the focus of your current research?

Dekel: I am interested in understanding how women cope following childbirth to understand the different mental health trajectories they take. On a societal level, we think of childbirth as a very happy event with happy outcomes. However, we know from research that a significant number of women report what is considered "postpartum blues"—basically a kind of stress that occurs shortly after childbirth. For some women, these symptoms become more enduring. My research investigates the impact of maternal psychopathology on a mother’s health and its psychological and biological manifestations in her child. The study of the mother-infant dyad will help us better understand mechanisms of intergenerational transmission of mental illness.

Given the fact that attending to a new baby might be difficult, we are trying to figure out what allows some women to be resilient and even grow psychologically and others to develop a more chronic postpartum illness. We also want to identify the working factors that may allow women recovery in the postpartum period from pre-existing clinical symptoms, as this trajectory is revealed by our data.

Q: Why is it important to better understand postpartum pathologies?

Dekel: There's a lot of work showing that postpartum problems, when a mother is not feeling well psychologically or emotionally, can have implications for the child that may even carry into adulthood. This means that postpartum psychopathology may result in transmission of the disorder's or its effects to the next generation. This is not so surprising, as the mother is vulnerable during a time critical to child development.

Current science really doesn't understand these trajectories well enough. At present, the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) includes only postpartum depression and postpartum psychosis as formal mental illnesses, but we are gathering more data from the field that actually show some women report other symptoms, such as anxiety, compulsiveness and even post-traumatic stress disorder (PTSD). I have spent the past few years here at Mass General focused on PTSD induced by the childbirth experience.

Q: How are you studying different mental health trajectories in new mothers?

Dekel: I have been working in collaboration with the Department of Obstetrics and Gynecology to conduct a prospective study of women who deliver at Mass General to understand different mental illness and mental health outcomes following childbirth. We are studying women during pregnancy to understand their mental health baseline before childbirth, in the hours after parturition to identify their immediate emotional response to the childbirth experience and a month and a half later to really understand the course of their mental health.

We have already surveyed over 500 women. This productive enrollment is largely due to the great support of the Obstetrics Program and study collaborator Anjali Kaimal, MD, director of Obstetric Research Program. We see that the vast majority of women report psychological growth in the wake of childbirth, yet for others the postpartum period is a time of vulnerability. I'm hoping that once we are able to better characterize these illnesses and understand their courses, we can then move to the next step—developing more novel, effective and feasible interventions.

We also need to identify biomarkers for these specific conditions to help us understand how potential interventions are interacting with the brain.

Q: How does treating postpartum PTSD differ from treating PTSD from other traumatic events?

Dekel: With general PTSD research, one of the challenges is being able to prevent the condition because it's very difficult to offer treatment to those who are exposed to a traumatic event. Ideally, you want to treat individuals at risk for PTSD in the very immediate wake of the exposure, in the first hours or days, which is almost impossible in other stressors.

But in the case of childbirth, there might actually be a really good window of opportunity to prevent the pathology, at least for some women, since they are in the hospital two to four days following delivery and are engaged with the medical system. In that sense, it's relatively doable to come up with good screening to identify those at risk and even offer secondary prevention measures.

In our prospective study at Mass General, we were able to identify women who reported acute stress symptoms at a clinical level immediately following childbirth. Ideally with more research we can develop specialized interventions that target the special needs of mothers.

Q: What new PTSD therapy is your lab currently developing?

Dekel: We have a hypothesis that there may be an oxytocin deficiency for mothers who are vulnerable to postpartum pathology, be it depression or more anxiety-driven symptoms. Based on this hypothesis, we're now testing the efficacy of intranasal oxytocin given to at-risk mothers during the first days after childbirth.

Previous research has shown that endogenous oxytocin produced naturally in the body relates to better bonding and higher levels of oxytocin may mean that the mood is better. We know postpartum pathology is often implicated in poor maternal bonding—if you're depressed, it's very difficult to attend to your baby. We're hoping that if we treat women who might have a deficiency of oxytocin during the time of critical mother-infant bonding, this will boost maternal bonding.

I received a grant from the NIH to test this intervention. We are now recruiting women for this study with the support of the OB/GYN Department and my collaborator Anjali Kaimal, MD, MAS. The pilot phase was conducted with the generous support of Mass General’s Claflin Distinguished Scholar Award.

I received a grant from the NIH to test this intervention. We are now recruiting women for this study with the support of the OB/GYN Department and the nursing staff in the outpatient and postpartum units. I'm working on this project with an interdisciplinary team of collaborators from psychiatry, obstetrics, and internal medicine. Among them are my collaborator Anjali Kaimal, MD, MAS, Elizabeth Lawson, MD, director of the Interdisciplinary Oxytocin Research Program, Lee Cohen, MD, director Center for Women’s Mental Health, Roger Pitman, MD, director of the PTSD Research Laboratory, and Lauren Hanley, MD, co-chair of Mass General's Baby-Friendly Hospital Initiative, and Linda Mayes, MD, director of the Yale Child Study Center. The pilot phase was conducted with the generous support of Mass General’s Claflin Distinguished Scholar Award and the Brain and Behavior Research Foundation’s NARSAD Young Investigator grant.

We're not waiting for women to develop problems three months postpartum when things may already be very difficult for them and for their baby. We are trying to prevent, or at least really decrease, the very immediate, very difficult time when the woman comes home and there are all these new things. Ideally, the focus during this time is on the bonding.

Q: What biomarker studies are you conducting?

Dekel: Currently the characterization of childbirth-related PTSD is still largely unknown. Therefore there is a need not only for strong psychological assessments, but also for more objective biological markers that will enable us to better understand this postpartum condition.

By analyzing hundreds of women through questionnaire-based research, we found that childbirth-related PTSD was evident even among women who had an at-term delivery with healthy outcomes. We're now taking that study to the next step and looking into the biomarkers of childbirth-related PTSD.

To do that, we brought women at high risk for childbirth-related PTSD to our lab for objective assessment of their PTSD that goes beyond their reported symptoms. We are integrating psychological and physiological measures and we'll be adding neuroimaging techniques soon to better characterize the biological underpinnings of childbirth-related PTSD.

Q: What is the potential impact of this research?

Dekel: In the United States, there are roughly four million babies born each year. If approximately 20% of those mothers experience postpartum pathology, including anxiety, depression or PTSD, there are a lot of women out there who might not be doing so well. As scientists, our mission is to better understand the pathology, the risk factors and the underlying biomarkers of the condition so we can help these women. There's so much hope in this work.

For childbirth-related PTSD, our study might encourage revision of the formal recognition of mental illness with postpartum onset by expanding the spectrum to include disorders of traumatic stress. Our study may call for screening women in postpartum hospital units for risk of childbirth-related PTSD beginning at parturition. This currently does not exist in routine obstetrical care.

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