Book Review: Understanding Your Moods When You're Expecting

This is a review of Understanding Your Moods When You're Expecting, by Lucy J,. Puryear, M.D.

Puryear is a psychiatrist specializing in women's reproductive mental health at Baylor in Texas, and she's seen tons and tons of women at all stages in pre-conception, pregnancy, and postpartum problems. She says she initially thought she was going to be an ob-gyn, but found that she'd have no ability to help women with their moods and emotions during the pregnancy because of the limitations of the system, so she switched to psychiatry. Now she works with women before, during, and after pregnancy.

The wonderful thing about this book is that Puryear continues to emphasize that it's normal and acceptable to feel depressed, scared, angry, and even hopeless during pregnancy. That, to me, is a huge step, that a mass-market publisher has published an entire book talking about women's negative feelings in a way that validates us. Those of us who have been depressed during pregnancy know that it's such a turbulent mix of mega-hormones, life changes, and emotional vulnerability that depression is a reasonable response from our bodies. But it's still so important to hear that it's normal from the medical establishment (which for years told us we should be happy and glowing, that serious nausea was "only morning sickness," and made us feel like we were going to be bad mothers if we didn't absolutely love pregnancy). So I'm thrilled that this book is out there.

Puryear writes with an easy, authoritative tone. The book is full of anecdotes about her patients, most of whom she treats with talk therapy, some of whom she treats with anti-depressants. She emphasizes the need for family support, which could be critical for a reader who was trying to hide her depression from family and friends because she was scared of their reaction to it. She also covers some interesting topics, like how to process pregnancy body changes if you have a history of eating disorders and body dysmorphia. The section on telling postpartum psychosis (having persistent thoughts of harming your children) vs. postpartum OCD (having persistent thoughts that something bad is going to happen to your children and trying to prevent it) is extremely important and will probably result in hundreds of women getting treatment for PPOCD who otherwise would have thought they would be seen as monsters.

There are a few things I wish were different about the book, though. The most glaring things for me are that she doesn't talk enough about alternate treatments for mood disorders and her section on breastfeeding is a big cop-out.

She does have a very brief section on St. John's Wort and Omega-3s during pregnancy, but not postpartum. She also doesn't mention any other treatment options for pregnancy or postpartum, even things that we know about--massage, B-complex vitamins, exercise, etc. It doesn't really surprise me, since she's an MD so her focus is on talk therapy and medical treatments, but it would have been nice to have this be a big book of what-to-do as well as a big book of you're-normal-and-you-can-get-through-his.

My real beef is with the section on breastfeeding, which I just think wasn't completely researched. There is evidence from all over the world that both mothers and babies do better when they are supported in their efforts to breastfeed. It should be treated as a normal part of the process, and we should be giving women all the tools and support we possibly can to help them have successful breastfeeding experiences. But Puryear seems to approach nursing as an expendable option, the first thing to go when a woman feel stressed postpartum. The anecdote she uses tells of a woman who comes in with a 6-week-old who isn't breastfeeding very well, and she's afraid she isn't making enough milk. She's tired and stressed out and her husband's at work all the time. (Sound familiar? Growth spurt at 6 weeks, fear of low supply, worst phase of baby crying and fussiness?)

Instead of saying a) we need to get you to see a great, IBCLC lactation consultant right now to figure out why the baby's not nursing well and whether you're actually having supply issues, b) we need to get you some help at home, and c) your husband is going to have to take a night shift or two with pumped milk or formula so you can get some sleep, Puryear tells her to stop breastfeeding. Now of course it's OK not to nurse your baby. But to me this sounds like a patient coming in with a broken toe and the doctor saying "Let's amputate the foot." Why not deal with the core issue, which is lack of support, to help the mother get some rest and either get the nursing straightened out or know she had all the support she could have before stopping?

So. In general I think this book is great, and is a vitally-important step in having the medical establishment and society at large treat women's mood disorders during pregnancy seriously. But if you're entertaining any thoughts at all of nursing, skip that section in this book. Make sure you've done some research before you give birth and have the phone number of an IBCLC lactation consultant on your refrigerator and don't hesitate to call if you're having any nursing issues at all. It doesn't guarantee that you'll be able to nurse successfully, but at least you'll have a fighting chance. 

Link here to my series on Preventing PPD.