Five Questions With: Dr. Margaret Howard

Associate director of the Women & Infants/Brown University Women’s Mental Health Fellowship talks about behavioral health treatment for women. More

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Five Questions With: Dr. Margaret Howard

"Sleep disturbance and vasomotor symptoms (i.e. hot flashes) can lead to irritability, fatigue, and mood changes."
Posted 5/12/14

Dr. Margaret Howard is the associate director of the Women & Infants/Brown University Women’s Mental Health Fellowship and serves as the vice chair of the Care New England Brain and Behavioral Health Council. She is the primary Women & Infants Day Hospital rotation supervisor for clinical psychology residents and also supervises psychiatry residents, primary care residents and Brown medical students.

She received her PhD. in clinical psychology from Southern Illinois University. She completed her internship and postdoctoral fellowship at The Warren Alpert Medical School of Brown University’s Department of Psychiatry and Human Behavior. She has served as the director of the Mother Baby Perinatal Psychiatric Partial Hospital (Day Hospital) at Women & Infants Hospital since 2000.

PBN: How crucial is it to research and treat women as a distinct population when it comes to behavioral health?

HOWARD: There is substantial epidemiological data indicating that women are diagnosed with particular psychiatric disorders at different rates than men. Compared to men, women are twice as likely to be diagnosed with depression or an anxiety disorder. Relatedly, men are much more likely to be diagnosed with substance abuse disorders and certain types of personality disorders.

Additionally, females may respond to adverse events and environmental stress differently than males, which can influence the type, timing, and susceptibility to subsequent psychiatric illness. Finally, emerging evidence suggests that women and men may differ in their response to pharmacological and non-pharmacological treatments. More specific understanding of these mechanisms is critical in planning optimal treatment interventions.

PBN: Your research is largely focused on women of childbearing age. What are some of the behavioral health issues that begin to emerge in women as they leave their child-bearing years behind?

HOWARD: Sleep disturbance and vasomotor symptoms (i.e. hot flashes) can lead to irritability, fatigue, and mood changes. Although there is some controversy, most well-designed studies confirm that the menopause transition represents a time of increased risk for depression and anxiety. While many women welcome the cessation of their menstrual periods, others believe that this marks declining vitality, which can be experienced by some as distressing. The menopause transition also coincides with emotional and social commotion as children leave home, primary relationships shift, and aging parents require care and attention.

PBN: How often do new mothers miss the signs of post-partum depression in themselves, and what are the best ways for spouses, friends, or family members to broach the subject if they think there is post-partum in play in a mom who doesn’t think so herself?

HOWARD: Many new mothers misattribute signs of depression to just having had a baby. Childbirth involves tremendous physical, emotional, and psychological upheaval and also represents a time of heightened vulnerability to depression. Fatigue, worry, irritability, and tearfulness occur in up to 85 percent of women but diminish by the third postpartum week. These “symptoms,” called “baby blues,” are not considered a depressive disorder. In contrast, postpartum depression is characterized by two or more weeks of daily sadness, loss of interest or pleasure, sleep disturbance, appetite disturbance, guilt, rumination, indecisiveness, poor concentration, and diminished functioning. Frightening intrusive thoughts of harm befalling their baby as well as suicidal thoughts are not uncommon.

Concerned loved ones are advised to offer nonjudgmental support, extra help with baby and chores, and encouragement to call or make an appointment to discuss these symptoms. Most women have developed a trusting relationship with their obstetrical provider who can facilitate referral to a perinatal mental health specialist.

PBN: What have been the most dramatic gains in treating women’s behavioral health in the past decade?

HOWARD: One important gain has been the abolishment of the notion that pregnancy decreases a woman’s susceptibility to psychiatric disorders. Historical “wisdom” attributed depression or anxiety symptoms to what was erroneously considered normal fluctuations in mood brought on by pregnancy. Research has refuted the myth of “pregnancy as protective,” and it’s now widely accepted that the prevalence of depression, anxiety, and other major mood disorders doesn’t diminish during pregnancy.

Related, there’s been an upsurge, in the past decade, of studies focusing on the most effective treatments for pregnant women. These studies range from safety profiles of anti-depressants, which are the most studied medications in pregnancy, to interventions such as prenatal yoga, exercise and bright-light therapy. Another influential finding has been that fetal exposure to anti-depressants resulting in cessation of maternal depression is associated with better outcomes than fetal exposure to untreated maternal depression and anxiety. A relatively new and promising area of gender research is the influence of reproductive hormones on mood regulating neurotransmitter systems.

PBN: About what percent of new moms suffer from post-partum depression? How much better is diagnosis of post-partum these days compared to a generation ago?

HOWARD: Up to 20 percent of women experience depression after delivery, making it the most common medical complication of childbearing. Early identification and treatment is critical to avoid prolonged suffering in the mother and adverse impact on the developing infant. Our ability to diagnose postpartum depression and public and provider awareness has advanced considerably compared to a generation ago. It’s not uncommon to have a mother accompany her daughter (and grandchild) to one of our programs and hear the grandmother say, “I had this, too, but no one ever talked about it back then.”

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