In this transcript from our Nyssa: The Unmentionables podcast, Nyssa's Mia Clarke speaks to Dr. Pooja Lakshmin, MD about anxiety, our relentless culture of productivity, identity shifts in motherhood, the stigma that still surrounds prescription medication, racism within the medical community and much more.
Mia: Hi Pooja, so great to have you on the podcast.
Pooja: I'm so excited to be here, it's great to chat with you.
Mia: Excellent. Well to start with I was wondering if you could share a little bit about who you are and your path to becoming a psychiatrist, what initially attracted you to that field, and why did you decide to focus on women's mental health and perinatal psychiatry specifically?
Pooja: Yeah, absolutely. I'm Doctor Pooja Lakshmin, I'm a perinatal psychiatrist which means that I take care of women who are pregnant or postpartum and dealing with mental health issues like postpartum depression or postpartum anxiety and I also specialise in women's mental health in general, so I take care of patients who aren't pregnant as well. And I live in Washington DC and am also a contributor for the New York Times parenting section, so I really enjoy writing… You know it's a question that I actually think about a lot because I actually really feel like I've found the perfect field for myself, and the career that I have right now is one that I very much designed after going through just a lot of different iterations, and really just questioning and trying to figure out what is the right place for me. I grew up in a family where my father is an anaesthesiologist, I'm Indian American, definitely in South Asian culture there's this track of "Well you're going to be a doctor, right?" (laughs) So that definitely I think was there for me, and as an undergrad at the University of Pennsylvania I was a women's studies major and I also majored in - there it was called Biological Basis of Behavior - so sort of psychology, neuroscience which, looking back, really sort of set me up for being a psychiatrist specialising in women's mental health. But at that time I didn't even know that that was a thing that I could do, and when I went to medical school originally I thought I was going to be an OBGYN, but I did that rotation first and I hated being in OR. I do not do well without sleep, so that was just not going to be the right fit for me. And then I did psychiatry last and I ended up just really… within the first week I was like: These are my people. I just really love being able to talk to patients about what's really going on and how to get to those deeper truths and look at sort of what's underneath, what's invisible. And in medicine psychiatry is so very much… you know there's still a lot of stigma, so… I was afraid, I was worried how people were going to react when I said I'm going to go into psychiatry… Well my family and my friends and my fellow med students and things like that, because it's sort of considered, like, not a real doctor? But I was really lucky that my family was supportive and things like that. It's definitely been a journey for me. I took some time off for my Psychiatry Residency training after I went through a divorce, and really did a lot of soul searching, you know, dealt with my own burnout and my own issues with depression in the past, and so for me it's very much been a professional journey and a personal journey I think, tied together. But now I've been in Washington DC for six years and I came on the faculty in 2016 after I graduated, and I have a private practice here in DC, and I get to write, and I'm doing lots of social media… And so I really feel like I've put it all together to fit my personality, which can be hard to do in medicine.
Mia: (Laughs) Yeah, you know I'm really glad you found true calling in that space. You know it's fantastic that you do have this expertise that you can… Like you said you work for the New York Times as well, you're seeing patients, you're on social media, I think that's really great.
Pooja: Yeah I think it's so important to be able to kind of feed this... different parts of our personalities and not feel like there has to be just one thing that we do.
Pooja: Especially if you're somebody who's creative.
Mia: Yeah, exactly… Because I think that's also a bit of a stereotype isn't it, that if you're a doctor maybe you're not that creative but I mean that's not the case. And would you say that you identify as being a creative person?
Pooja: Yeah I think over the past few years I've really let myself lean into that, and I think that's one of the ways Psychiatry is so nice because Psychiatry is a field that really does encourage folks to allow their creativity out, and I think just because of the fact of the nature of the field I think there's more space to write and express yourself. So that's something that I think has really helped to be part of my own self care, you could say.
Mia: You're also a clinical supervisor in the five trimesters perinatal psychiatry clinic at the george Washington university school of medicine. So we typically think about the trimesters as being three trimesters of pregnancy, then the fourth postpartum trimester, and sometimes the fifth trimester is thought of as being that time that many birthing people return to work, which is a term that's been coined and popularised by Lauren Smith Brody who's an author of The Fifth Trimester and a former guest on this podcast. So how do you and your colleagues think about the sequence of trimesters?
Pooja: So this clinic was started in 2010 by my colleagues Dr Lisa Catapano and Dr Julia Frank, and the way that they conceptualised it is: the three trimesters of pregnancy, but that there's a trimester before you get pregnant. The whole process of deciding to conceive and becoming pregnant itself is the first trimester, and then the postpartum trimester - what happens afterwards, what happens after you have your baby. Those are the kind of women we see in our clinic, and especially for women who have had trouble with depression or anxiety in the past that, you know, what we call that first trimester, when you decide I want to have a baby, how do I take care of myself… If you're taking anti-depressants, what do I do about my anti-depressants, do I stay on them? We do lots of consultations with women around how to make sure that they can set themselves up to minimise the risk of having some type of decompensation during pregnancy. And then of course after delivery, all of the work we do treating women for postpartum depression, postpartum anxiety, things like that.
Mia: I find that so fascinating, because obviously at Nyssa we've adopted that term the fourth trimester to be that postpartum time, but I think it's so fascinating to think of that time before you actually get pregnant as being a trimester in and of itself. It took me three years to conceive my daughter, so I really felt like, in that time that I was having fertility treatment and obviously it takes a huge emotional toll. It prepared me for parenthood in a way that I don't think maybe would have happened than if it had just been instant… I just think that that's really interesting, to think of that stage in and of itself.
Pooja: I think it really is such an important time psychologically, because so much happens in terms of that decision as women to become a mom, right? That's such a huge shift in your identity, and it's so common to feel ambivalent about it.
Mia: I think more common than people realise. I think that's a huge taboo, right? Is to just be like I really don't want kids, or I'm not sure…
Pooja: Right, right. That's definitely an unmentionable, I think you could say talking about that and not qualifying it with "But I'm sure that I will!" or "I'm sure I'll change my mind", you know, kind of trying to kind of dismiss it. But absolutely, there's so much that goes into that processing, and I think that especially if you're somebody who struggled with infertility or it takes a while to have a baby, even more so - that you're really kind of preparing.
Mia: That's really interesting. So there's been a huge cultural shift in terms of awareness around mental health generally, which is really necessary. And so what really excited you about this shift, in terms of just this impact on the way that women live and work generally?
Pooja: Yeah, I mean I think definitely our culture has gotten so much better about talking about mood and anxiety disorders, about seeking therapy, seeking treatment… But I think there's still a really long way to go. I think we're talking about it, but I think there's still a lot of stigma with actually having depression. One thing that I see is that I think it's really easy for… when women come to see me, it's a lot easier for them to get diagnosed with an anxiety disorder, or to talk about the fact that they feel anxious, but it's a lot of more difficult when it's depression, or actually sort of sitting with the feeling that they are depressed.
Mia: What do you think's behind that?
Pooja: I think that we live in a culture that's just so productivity oriented, right? And anxiety is a feeling state that actually can lend itself to motivation. For a lot of folks, you know, for me anxiety is a driver, right? It makes me meet my deadlines, get things done. And anxiety is also an emotion that has you move quickly, right? Just doing more and doing more. So it's culturally it's a lot more casual, it's just easier to be like "Yeah, I'm stressed out… Yeah, I have anxiety", but once you kind of say "I have depression" people kind of look at you differently. And I think a lot of times folks don't realise that you can be someone who's high functioning, you can be getting your kids off to school every morning, you could be cooking dinner every night, you could be in the boardroom presenting to investors… And you could still have depression.
Mia: Have you noticed that there's a difference between men and women - do women lean more towards saying that they have anxiety than men, or do you think that's just a general thing?
Pooja: To be honest I don't treat men anymore...
Pooja: So it's been almost a year and a half since I've seen a male patient actually. In general women are much more likely to get treatment, to come in for mental health treatment at all… But I think it's hard for both genders to really talk about these things, and I live in Washington DC so it's definitely a place where you have folks who are really high functioning, very highly educated, really ambitious… So there can be a lot of anger too underneath the depression, kind of a frustration and a fear of really opening up into some of those darker feelings.
Mia: Yeah I totally get that. Well I read recently that 62% of people believe that the health and intimate experiences of women aren't talked about openly enough, and that 40% of women feel that their mental wellbeing is affected as a result of not being able to speak about their intimate experiences. So I'm just curious about your take on that and what unmentionable topics related to the experience of motherhood that you see most affecting our mental health.
Pooja: Yeah, I think that that's something that we see in the literature about postpartum depression and postpartum anxiety around what stops women from getting help. This feeling of shame, and of not feeling like you have anybody in your life that you can be fully open with and let them know that this is what you're feeling? And so that kind of contributes to why, for some women, they feel like it's impossible to seek out help. You know I feel like there's so many things that fall into this category? I think when it comes to motherhood… Like we were kind of talking about this earlier, this ambivalence. It's like being able to voice doubts, being able to say "Gosh, my kids are driving me crazy", or "I regret having kids". You know some of these things where you're really letting that truth out there? A lot of times when I see women talking about how hard it is to be a mom, it feels like there needs to be this immediate qualification: "But I love my kids so much", like, you can't just let it stand alone: "It is really hard to be a mom". There was that great piece in the New York Times about mom rage and I feel like that fits so much. Women actually being able to express their anger and their frustration, especially in a time like this right now, during the pandemic, where families and women are just left hanging here in the United States. So those are some things that come to mind. I think also, in terms of women's mental health, like I was saying really speaking openly about depression, and speaking openly about suicidal thoughts, or suicide attempts, or having psychiatric hospitalisations… Some of these more severe situations and manifestations of depression or anxiety that I see with patients, that it's still really hard to talk about those things.
Mia: Yeah, I really feel that people are getting more familiar with postpartum depression, but things like postpartum psychosis and postpartum OCD… it's still just not talked about.
Pooja: Right, right. And one of the things I post a lot about on social media, on Instagram - I feel like I'm talking about it all the time, because whenever I post about it I get so many messages - about those postpartum intrusive, scary thoughts of harm coming to your baby, which we know actually are normal. You know there was a study of 100 mom's and found that every single one had unwanted, intrusive thoughts of accidental harm coming to the baby. 50% had unwanted, intrusive thoughts of intentional harm coming to the baby. When you have OCD those thoughts are so sticky and so persistent and women are so afraid - and you know I don't blame them either… I don't blame them for being afraid of talking about it, because there's just so much judgement that goes around and there's so much shame I think that comes with those thoughts. But I think having folks that work in mental health ON social media - that's why I think it's so important to share this information because so many moms are on social media - that's where you are in the middle of the night when you're nursing your baby! (laughs)
Mia: Yeah totally. I think that's a huge part of why we love the work that you do because I think it makes my heart hurt to know, like you said, that every single parent has these thoughts of harm coming to their child, yet we don't talk about it so we can't comfort each other and know that it's normal, so it's so essential to just get these facts out there and talk about it.
Pooja: Right. Because it's just so isolating.
Mia: Yeah. And even you know, like you said I think, earlier you mentioned "Oh what if I regretted having kids" - I feel like that's SUCH a taboo to say that, right? I've very rarely heard anyone say that without a qualifier… Again I think that's something that's maybe a lot more normal than maybe people talk about - even, in my case, like, I very much need alone time in order to be a good mother… I have to have an hour to myself every day. That's kind of a non-negotiable act of self care for me. Sometimes I mention that to people and they think I'm like…
Pooja: Right, indulgent, right?
Mia: Just need to talk about these things.
Pooja: And I think part of that is like seeing women and moms as, like, full human beings, right? Your role is not just 'Mother'. And I think that's this way that our culture really holds moms up on this pedestal, but also can demonise them too - it's like this polarising role (on?) our identity.
Mia: In many people's cases you can be a better mother if you are taking care of other aspects of your identity.
Therapy is becoming more normalised as a strategy to help with mental wellbeing, but I'm curious, as a psychiatrist, have you noticed that people tend to be a bit more comfortable engaging in therapy than they do taking medication to support their mental health plan? I know some friends who have pretty severe anxiety and depression, but they'll do therapy, they'll do acupuncture, change their diet - all kinds of things - but are quite resistant to seeing a psychiatrist and potentially taking medication. So I'm just curious about your thoughts on that.
Pooja: Absolutely, 100%. I think that there's still a huge stigma about taking medication, especially when it comes to pregnancy or while you're breastfeeding. When patients come to see me they are usually very very afraid that I'm going to recommend medication. And I don't always recommend medication, you know the treatment of choice for mild to moderate perinatal mood and anxiety disorders is psychotherapy. But if your symptoms are moderate to severe, then medication like antidepressants is indicated along with therapy. I think it's the sense that… people have this misconception that taking medication like an antidepressant is kind of cheating? Like using it as a crutch? Like you couldn't do it yourself, you need something else? Or they think that they're going to become addicted to the medication, which is not the case, you can't become addicted to an antidepressant. And I always say, like, if you broke your leg and the surgeon said you needed to get surgery, are you going to be like "Nope, sorry! I'm just going to do it on my own! This bone is just going to heal itself!" Right? And the other thing too is women will often say, like, "Look, I don't need medication, I just need to sleep more, I need a partner who's actually going to help me with the laundry and take care of the baby… Like, that's what I need". And I'll say yes, and that is absolutely true, those things are really important for your mental health, but when you're depressed what happens is that if we divide the brain into two parts - simplify the brain - and we say there's a part of your brain that feels all the feelings, and then there's the other part of your brain that does problem-solving and strategizing and complex thinking. When you're depressed or when you're anxious the volume on the feeling part is just sky high, and your problem solving part of the brain, your cortex, is sort of offline. So what antidepressants do is they balance that, they turn the volume down on, a little bit, on the feeling part and they bring the problem solving part back online. So then, when you're in the heat of an argument with your partner about how he needs to help you more, you actually can access your problem solving brain and talk rationally and linearly about what he can do to help you, versus just bursting out into tears or feeling completely hopeless or overwhelmed. So it's like you need that proper regulation or your brain chemistry to actually be able to then make the choices and communicate the things that you need. Same as with therapy. I mean therapy does that too, but if your symptoms are so severe then you're going to be in therapy talking and talking, but you won't actually be able to implement any of the skills.
Mia: That's really fascinating, I've never heard it spoken about that way, that's really interesting.
Pooja: Yeah, and medication… It's not a magic pill either. I think sometimes people think "Oh, if I take medication, everything's going to be fine, I'm not going to need to worry about anything". That's not true either, you still need to go to therapy, you still need to exercise, you still need to set boundaries and make good choices for yourself. But it's all kind of part of a program, and everything sort of feeds into each other.
Mia: It's all connected
Pooja: Right. And so I think often that's how I explain it. And even with that still it takes people typically a couple of visits before they are ready to decide to try starting a medication, and another piece of it too is finding a provider that you really trust, and that you feel like can work with you, and then it's a partnership, not somebody who just handing you a prescription and just saying good luck.
Mia: That's a really interesting way of thinking about it. I'd like to talk about racism in the medical field… it's rampant, that's something you've been very open about. So you've shared that the maternal death rate for black women is much, much higher than it is for white women. And obviously this is deep down to… deep systemic racism in the fields of obstetrics and gynaecology, but I'd like to know your thoughts on racism in psychiatry - what are some of the critical issues that you feel need to be addressed and really happen to create proper, lasting change.
Pooja: Well I think in my field in particular - in maternal mental health - we know that African American women are more likely to suffer from depression during pregnancy and postpartum. They're also less likely to be diagnosed and less likely to receive treatment. I did an Instagram Live a couple of weeks ago with Dr Crystal Carp, who is a perinatal psychiatrist in Chicago and the president of the Marce society, she's African American, and we were talking about how critical it is for black women to have providers that are also black, and being able to share your experiences and talk to somebody who looks like you? I think there's so much mistrust in medicine in the black community, and rightly so because there's been so much racism and abuse and bias and so it makes sense. Outside of maternal mental health, you know there's a lot of studies in psychiatry looking at how - with people that have psychosis - that African American patients are more likely to be diagnosed with schizophrenia or with a psychotic disorder, as opposed to bipolar disorder or depression. They're less likely to be asked about their mood symptoms and psychotic disorders tend to be more stigmatised in our culture, in comparison to something like depression or bipolar disorder. So there's all of these ways in which racism certainly shows up, and I think that there's a lot of work to do, and I think part of it is in terms of patients and taking care of patients, but then the other side of it is within the medical field and how African American medical students, residents, attending faculty members: how they are treated as well. So it's really nice to see, with everything that's going on right now in the States, a lot of these issues are getting more attention. But there's a lot of work to do.
Mia: Yeah, definitely. And when you're a psychiatrist in training, is this something that's talked about? When you're a young medical student?
Pooja: Not enough. It depends on the program that you go to and it really depends on the culture of the place? But no, definitely not enough. It's not given the priority that it should be.
Mia: Yeah. But hopefully as these conversations continue to happen they will become more and more a priority in programs. What I would love to talk about: this project that you're working on, 'Gemma'. So I know this platform is very much in its infancy still, but what is it and why did you start it?
Pooja: Yeah, absolutely. Well I started doing Instagram professionally in about December of 2018 I think, and so over the year and half that I've been on Instagram I get so many messages asking me questions about medications, and perinatal mood and anxiety disorders, and women that are just like "I have no idea, my doctor didn't tell me anything about this, I don't know what to do, I don't know where to go…" And as a physician I can't provide medical advice on social media, and social media isn't a place that you can get therapy either, right? So you have to be really careful. In this process I just thought there just needs to be more evidence based resources, there need to be more places that women can go and know that the information that they're getting is vetted and getting information from other sources that are reputable other medical professionals. And so this past May I launched the first kind of pilot program for Gemma? It was a four week virtual course, small group course, where I had twelve women, and it was all about pregnancy, postpartum, and mental health. So essentially my whole Instagram page accepts, like, a class (laughs) where I get to kind of teach everything, and then we have a Facebook group, and there's homework, and things like that, and women get to interact with each other. And it was so much fun for me to be able to actually engage with other women in real time. And the feedback that I've gotten has just been really amazing - women saying that they learned so much, but also that they felt like having this information kind of empowers them to be able to go back to their healthcare providers and ask the right questions, advocate for themselves, seek out therapy, ask about medications. And because they had this data, and because they had all the information in the course they felt a lot more confident asking those questions.
Mia: That totally makes sense. When I was pregnant I'd do a lot of research online, I'm not recommending you do, going down a Google rabbit hole (laughs). But I felt like I needed to have knowledge so I could understand what terms were being said to me by my doctor, and feel like I had some sense of what was going on, in order to even have those ?conversations in the first place. And I think that's fantastic.
Pooja: Right, and you know when I was starting Gemma and and talking to… trying to find insurance and dealing with all these things… People were like "I don't understand, who is the class for? Why would people take… Are they students? Are the doing, like, a certificate?" And I'm like no, this is for Moms! This is a class for Moms. And all the men that I talked to were like "Why would they take it?" And it's just like well no, you don't understand that our medical system is so complicated that yes, something like this should be covered by insurance. And I would love to be able to grow Gemma to the point where that could be possible. But you know healthcare providers don't have time, you have ten minutes with your doctor. So all of this stuff, as a patient, you have to figure out on your own, so you're on Google, or you're on Instagram. And the thing too with perinatal mood and anxiety disorders, I feel like women don't really understand that there's a lot actually that you can do from a prevention standpoint? You know right now it's just like: "Fingers crossed! Hope I don't get it!" So, in the class we do kind of really go through: Here's some evidence based strategies that you can use to minimise your risk of having postpartum depression, or having postpartum anxiety. So I've done three pilot courses for that, and then the next offering is going to be more of a condensed workshop, not on perinatal mood and anxiety disorders, but on Mom guilt and dealing with your inner critic, and figuring out how to learn to talk to yourself more kindly as a Mom. So that's going to be one that will have some prerecorded offerings and exercises that you can do, and then there'll be a live portion as well. So if you're listening in, you can go to the website which is www.gemmawomen.com and you'll be able to sign up and register there. So I'll be launching that soon, it'll be sometime in December. I'm really excited for that too. You know I'm really passionate about teaching the clinical stuff but also the stuff that's sort of complementary as well, because I think that's equally as important. And I think it's nice and helpful to get back material also from somebody who has a background in clinical work.
Mia: I think it's so great. Thank you.
Pooja: Yeah, absolutely, thank you. You know my background is in medicine, I've never started a business before - well I had my private practice, but that's kind of different - so this is all a whole new world for me so I'm trying to figure it out and see what works. But the fun part for me is just getting to engage with other women and learning.
Mia: Well actually that ties in then to my last question, as we asked some people in our community to anonymously share some questions that they wanted to ask you. I'll just pick one of them, this ties into what you were just saying about Mom guilt. "You've written about the importance of establishing healthy boundaries. I feel so guilty saying this but after being at home with my children for so many weeks during this time I feel utterly depleted. So how might a parent most effectively set boundaries with their kids?"
Pooja: That is a great question and you know what? Everybody feels like that right now, there is no reason to feel guilty because this is a situation that all parents are in. And the thing is as a mom you are still a human being! You are still a human being that has needs and thoughts and feelings and when you're constantly surrounded by your children, just like you were saying Mia, you need some alone time to be with yourself. So please don't feel guilty. You know one of the things that I like to talk about when it comes to guilt is that I think for women guilt is just sort of this homeostatic place that our brain goes. It's not actually a valuable emotion, it doesn't give you any new information. I was facilitating a moms group a couple of years ago and there was a woman who had a new baby with her but she had the option of taking a couple more weeks of maternity leave and she was like "I feel guilty… my team would need to pick up more work for me and I feel bad, but then if I do go in I'll feel bad that I won't be with my daughter, I'm losing out on that time with her". And it's sort of like: is there any decision where you wouldn't feel guilty? What are the situations in which you don't feel guilty? There are very few, if any. So I look at guilt more of a marker of structural problems. Like, the reason you feel guilty is that there is no good solution because there is no childcare, there's no good childcare options right now. And this is a separate topic but our government really has not provided good options for how to handle this pandemic. So we as women are more likely to internalise that and say "Well, I should be perfect, I should be able to manage this, I should be able to figure this out". So hopefully that alleviates a little bit of this load, for the person in the community who's asking this, but when it comes down to actually setting those boundaries I think being really clear… You know it also depends on how old your child is and kind of what the situation is with your child, but… just really kind of being clear and saying things like "Mom needs a little bit of alone time right now. I'm going to be in this other room for the next hour, reading. At 1pm I'll come out and then we can do your puzzle". You know kind of giving it a structured time period and saying I'll be back at this certain time. And then working with, if you do have a partner, really working with your partner to figure out how you can both have at least twenty minutes a day where the two of you get some time by yourselves, and looking at how the two of you together can navigate that. Because I think a lot of times… Women in my class... we talk a lot about maternal gatekeeping, right? Kind of this tendency for moms to take on all the work because they feel like when the partner does it they're not doing it totally right, or it's not perfect, or it's not exactly the way you would want it done… Kind of letting go of that so that your partner really can step in and fill in the gap so you can have a little bit of space for yourself.
Mia: I think that's so important. And when you do do that it's a kindness to yourself because you can get that time but you know it's a real kindness to your partner too. They should have that opportunity to be a parent too.
Pooja: Yep, absolutely, that's how you develop your identity as a parent, by figuring things out, by making mistakes and sorting through those things on their own. But if you don't let your partner do that then they're not going to feel invested, right? So I think for moms that requires bearing some of your own anxiety, working through maybe some issues that you might have with control, and letting go of control.
Mia: Well Pooja thank you so much. Really appreciate your time and perspective on everything. You really said some things that made me think quite differently about things, so, really appreciate it.
Pooja: Absolutely, such a pleasure being here Mia and I love everything that Nyssa is doing, I love all of your stuff and I'm really excited to do more with you guys. For folks that are listening you can follow me at @womensmentalhealthdoc on Instagram and we talked a little bit about Gemma, so the website is: www.gemmawomen.com and you can find out more information about the programs we have and the classes that are enrolling. And then the other thing I forgot to mention is I do also have a Facebook group that's specific for women who are pregnant or postpartum or trying to conceive during the pandemic. It's called 'covid-19 maternal wellbeing' - so you can just search that on Facebook. I think we have about 7500 or so members. It's just been a really good community of support for other women right now who are going through the same things to be able to share tips and tricks and get support, and also evidence based information too, so that's another resource.
Mia: I really love that because it's such a specific time if you're pregnant or giving birth postpartum right now, you can't Google that! (laughs) So this is so of-the-time, I love the fact you have a space for women to share their experiences there.
Pooja: Yeah it's been I think really helpful.
Mia: Well thank you so much!
Pooja: Absolutely, take care.