Did my ADHD make me more likely to have postpartum depression?

After her daughter was born, Rae Jacobson was hit by a bout of severe postpartum depression. Back then, there wasn’t much out there about ADHD and women, let alone ADHD and postpartum mental health.

Rae had heard that there was a link between ADHD and postpartum depression. But with a tiny baby to care for and a life to navigate, she had more pressing things to deal with. 

But the question kept bugging her: Does ADHD make you more likely to have postpartum depression?

This week on Hyperfocus, Rae finally gets some answers to questions she has had for years. Her guest is Dr. Catherine Birndorf, an expert on postpartum mood disorders and co-founder, CEO, and medical director of The Motherhood Center of New York.

We love hearing from our listeners. Email us at hyperfocus@understood.org.

Timestamps

(02:55) ADHD as a postpartum concern

(09:47) PMADs: Not just the ‘baby blues’

(14:21) What can struggling parents do?

(21:07) Medication and pregnancy

Related resources

• Catherine’s book: What No One Tells You

• 3 things I’m learning as a new mom with ADHD 

• 72 hours in the life of a working mom with ADHD

• Parenting tips when you and your child have ADHD

Episode transcript

Rae: After my daughter Alice was born in 2017, I was rocked by what felt like a totally unexpected bout of severe postpartum depression. Nine months of weeping, rage, disconnection, and massive terrifying anxiety. I still have a hard time thinking about it.

When it finally receded, I felt first, very glad not to be losing my mind anymore, but then baffled. What had happened? Why? I'd never been depressed before. Anxious sure. But depression? I've been caught so off guard, and I wanted to know what was going on. And what I wanted to know most was this: Why was it so hard? And the thing that bugged me more than anything else, could I have been more prepared?

I have ADHD, and I vaguely heard that it could put women at greater risk for postpartum mental health disorders. But, stunner, back then there wasn't much research. And to be honest, I was more focused on trying to figure out how to care for a helpless creature who relied on me for all things when I could barely, like, find my shoes or remember how to take a shower.

So, I thought about it, and then I let it go. I wondered, I worried, and I moved on. I had a growing daughter who was becoming more amazing every day. I had a job I had to do, and I had a self to figure out. Motherhood. Quite the learning process. Who knew?

But I'm a mental health journalist with a counseling degree, I have ADHD, and for years this question has nagged at me. If ADHD means women are more likely to struggle with serious issues like postpartum depression and anxiety, shouldn't we least be like, I don't know, talking about it? What might have been different if I had known the risks? And what do we know now that we didn't know then? And so, I did what I do. I hyperfocused.

I found article after article saying basically, "Yes, it does," and then nothing. So, I reached out to the person I knew might have some of the answers I was looking for. Dr. Catherine Birndorf, a reproductive psychiatrist and co-founder of The Motherhood Center, and an expert on postpartum mood disorders. Dr. Birndorf will be the first to tell you that she's not an ADHD expert. This I learned over years of interviewing clinicians is how you know a true expert. They immediately tell you what they don't know.

But she's a leader in her field and she's treated many, many women with ADHD as they try to navigate postpartum mental health challenges. She's charming, brilliant, and I got to ask her some of the things I've been wondering for literally years. I'm Rae Jacobson and this is "Hyperfocus." Here's my conversation with Dr. Catherine Birndorf.

So, are you cool just jumping in?

Catherine: For sure.

(02:55) ADHD as a postpartum concern

Rae: So, one of the reasons I was so excited to have you come and talk to me is because one of the things after I had my daughter in 2017, I had the chance to interview you and I had ridiculous postpartum depression. I know now. At the time it didn't really click with me, but I, you know, look back and it's like very clear. Like, "Oh, you're not supposed to be crying every day for a year. That's not really that normal."

Catherine: No.

Rae: And I also, I have ADHD. And the more I learned after I kind of understood what was going on and the more I got to know about postpartum depression and about, you know, the overlap that it has with ADHD, the more I thought like, "Gosh, I really wish I had known more about this." So, one of the things I wanted to ask you about is there's not a lot of great resources for women with ADHD, but there is a lot of evidence that ADHD can make you more vulnerable after you have a kid for so many reasons.

And I was wondering, you could tell me a little bit about what you see in your practice with women who have ADHD, who are having, experiences during pregnancy, postpartum, and, you know, what are some of the commonalities between those things?

Catherine: Well, first, what I'll tell you is generally not what people present with. So, you were talking about your own postpartum depression and didn't recognize that. And I don't know if anyone even thought about ADHD in that context. So, when I started in this field in the mid-nineties, no one was talking about postpartum depression, and it took many years after that. And so, I don't even know that we think of ADHD.

Like, I'm so excited to be talking about this because I don't think we think of it, that's not one of the first few things on the lists of things we talk about: anxiety, depression, bipolar illness, OCD, postpartum psychosis. And there's not enough out there about any of those things. And ADHD is not usually on the list. It's usually kind of secondary. So, I feel kind of bad for it as it is a disorder and for the people struggling with it.

And in fact, just, you know, free association, I just got in trouble with an insurance company because for some reason, I was putting down that someone's primary diagnosis was postpartum depression, but I also listed ADHD, and because somehow that went first, they denied us coverage. And they would have covered postpartum depression. Again, we've come a long way, baby, in terms of that. But like talk about where ADHD needs to go.

Rae: I mean, you've hit on something that is like horrifying in a number of ways, but specifically for women who are struggling with ADHD, also are struggling with postpartum and mental health. Even if you know what's going on, even if you understand what you might need, accessing that can be really, really hard.

Catherine: Well, and also, you know, I go to my child psychiatry friends, like when I was learning about ADHD, I went to them. They knew about it. I felt like I didn't get that in adult residency, right? Like, I don't feel like I understood it well enough. So, I've had to learn it a little bit on the job, so to speak.

But I, typically, when someone comes to me and says, "I really need help," so I'm like, "Let me get you to someone who's like, expert," and those are the child and adolescent people. But that's because we're not acknowledging or don't know, many of us, how prevalent it is in the adult population because it feels... People don't even know you can have it, get it in your adulthood. They think it's a childhood disorder, period.

Rae: Which is wild and something that, you know, when you work in this field, you sort of forget how little people know about this. And, you know, since the pandemic, so many women have been curious. Like they see things online. They start to wonder, "Is this me? It feels like it's reflecting me." But the amount of women especially — and I know many adults, but more specifically women — who've gone through their lives without the support that you get with a diagnosis, without the medication, without any kind of understanding of why things are so hard. It's crazy.

Catherine: It's crazy. And it makes me think of all the women who blame themselves for their inability to do X, Y, and or Z because, you know, they don't realize that there's something actually underlying that.

Rae: It's not just postpartum depression that women experience, though, right? Like when you have you get the pamphlets at the hospital and it's like "Are you not connecting with your baby?"

Catherine: Yeah.

Rae: Are you very sad?

Catherine: Yeah.

Rae: Well, I don't know. Mostly I spend time thinking about whether or not a tree branch is going to fall on her or whether the wind could, like, chill her to the point that, you know, like the old ladies tell me to put a hat on her. Should I put a hat on her? All I can think about is lightning striking our house.

Catherine: It doesn't always look like depression. You don't always report how sad you feel. Anxiety is, you know, one of the top symptoms of postpartum depression. It may also be postpartum anxiety. And there are many kinds. And just to be clear, we now say perinatal because at least 50% of pregnancy-related illnesses, particularly depression, start in pregnancy. And by the way, if you have a history of, you know, depression and anxiety and it's not treated or under-treated and then you get pregnant, it doesn't get better, it. Usually gets worse.

So, again, people are waiting around for the postpartum and it's like, wait, you're already having it. You had it before you started, or. you're having it during. I mean, it can start at any time or it can be a continuation of what was, if it's not treated. So, postpartum is really just timing. It happens in the postpartum, but it's really we believe at this point in time it's essentially the same bird and just it's the time of when it starts.

Rae: That's really interesting. I think people often think postpartum is the only, like sort of post-baby mood disorder you can experience. But it's not just postpartum, right? There's a whole bunch?

Catherine: No. Oh yeah. Yeah. So, the term we're using these days for postpartum depression, which is what people finally recognize as something, again years ago, we didn't talk about that. Now we can talk about that. But we've moved on to say perinatal mood and anxiety disorders or perinatal mental health. But I like perinatal mood and anxiety disorders because it sort of is the umbrella, the wastebasket for everything. So, perinatal.

Rae: OK, let's break that down for a second. Perinatal mood and anxiety disorders or PMAD for short, cute. Perinatal refers to both when a person is pregnant and after they give birth. And people often say PMAD interchangeably with postpartum depression. But PMAD refers to a bunch of different conditions that develop during this perinatal period, including depression, anxiety, post-traumatic stress disorder or PTSD, and obsessive-compulsive disorder, OCD.

(09:47) PMADs: Not just the ‘baby blues’

PMADs are super common. About one in every five new moms may develop one. They're also often very underdiagnosed, and they can be really serious. To be clear, we're not talking about baby blues if you've heard that term, and I asked Catherine about that.

Catherine: We do know that almost everybody has the blues, the baby blues, because at the end of pregnancy when progesterone and estrogen are super high and then you deliver the baby soon thereafter, they plummet. Like immediately postpartum, they plummet. And that fluctuation from high, high to low low, that delta, is what brings on this sort of mood fluctuation and this increased sensitivity and, you know, crying on a dime, feeling, you know, overwhelmed.

That's what we describe as the blues and that almost everybody has because everybody goes through that precipitous drop. So, that seems to be, it's that change. But most, some people don't notice it or it's not that big of a deal. But a lot of people have just like even a moment in time where they're just hypersensitive in a way they've never felt before and they're overwhelmed or they're crying when they're looking at something that's very happy. I mean, that's the blues. It's self-resolving.

Again, the statistics are somewhere like 85% of people have this. I always say you're the unusual person if you don't. And then generally speaking, it resolves on its own. So if you're having it past a week or two, two weeks on the outside, it's not the blues. It's like the blues gone bad and it's moved into something else that we need to understand.

Rae: There was another thing I'd been wondering about that I wanted to ask, Catherine. Can having a PMAD make ADHD symptoms more intense? Like you have already this inability to organize, you're struggling with executive functioning, you have a higher sensitivity — often the rejection sensitivity is something that's really common with women with ADHD. I know women with ADHD, myself included, often have a harder time around your period. Like my period is like, I would just like to be like, like not have to speak to anyone for the four to however many days leading up to my period because it would just be better for all of us.

Catherine: Yeah.

Rae: But I know that when people with ADHD experience that drop, that hormonal change, and then you have also like depression or whatever is coming afterwards, it feels like the symptoms of ADHD are going to make that harder to navigate. Harder to manage.

Catherine: Yeah, yeah. Yeah, I think that, again, I don't know that we can pin it on the hormonal changes. I think some people have a certain hormonal sensitivity irrespective of illness, but I do think that I think certain things are harder for people with ADHD and I just want to acknowledge that. And so, I think that organizing, you know, executive function, whatever your kind of brand of ADHD is because it's also multifactorial in expression.

Rae: There's multiple presentations.

Catherine: Multiple presentations of ADHD. So, you kind of, it can be hard to navigate when you're in this new period of time where you don't have any previous skill set or learning or behavioral interventions that you're used to, to, you know, remember and lean on to, you know, get through it.

Rae: And you're not sleeping.

Catherine: Oh, and you're not sleeping. So, yeah, there there are a lot of things that exacerbate it, right? Which is why I think that women, there is this recent, more recent study about women who have ADHD are five times more likely to have postpartum depression.

Rae: Wow. That seems like something that people should know.

Catherine: I think so.

Rae: Yeah. I mean, you know, we keep going back to it, but it'd be great if this was stuff that people could just have access to and then plan for and provide themselves with this softest cushion they have if you're five times more likely to have this than a neurotypical woman.

Catherine: Yeah. Very important to know.

(14:21) What can struggling parents do?

Rae: If I were like a client, so here I'm going to do a like, a quick roleplay thing. I come in, I am lucky enough to know that I have ADHD. I now have postpartum depression and I'm just sinking. I can't surface. I'm not functioning in the way that I'd like to be. I love my kid, but all I think about is what happens if she dies. You know, I think these are pretty common symptoms in surviving.

Catherine: I saw several patients like you, this person you're describing, earlier today. How's that?

Rae: There you go.

Catherine: Yeah.

Rae: So, take this sort of, like, slightly ideal setting. And what are some things that you would like, you know, from your genuinely professional opinion, what do you recommend to somebody? These are like, and I love general advice. I think it's beautiful and I want to always sort of dive into it because it's where I like to have fun.

But when we're thinking about how can we get the kind of things that women need if they don't have access to something awesome like The Motherhood Center, if they can't come to the day program, and they can't get these things from anything other than the resources that we're creating now, what are some actionable, practical things that you want that person to walk away with from this session?

Catherine: Well, first, I think just knowing that something's not right, I think is an easy step one. Even before you have a diagnosis, but you just know something's off. I often say to women who are postpartum who aren't getting the attention they want from their whoever, whatever doctor or midwife or whomever "If you know something's wrong, don't take no for an answer." And that's hard to do when you're depressed or anxious or you don't, you know, no one's going to believe you have ADHD or whatever it is. It's like you have to persist.

So, that's not taking no for an answer. That's asking for help from whatever health professional you have access to or can gain access to. And it's, you know, really just saying, you know, "I need help and what can we do?" And doctors, you know, in the medical profession, we don't like to not know. We are people, we are knowers and we are definitive and we like to be like, "Yes, we are confident." But the truth is that you don't have to know everything.

And I think that a lot of doctors don't ask about how someone's doing because they don't want the answer. They don't want someone to tell them something that they don't know what to do about it, right? It's like if someone says, "I have ADHD" and it's not something you know about, you're like, "What do I do now?" Right? But like, who cares? Right?

I think you have to be confident enough in your abilities, know what you know, and know what you don't know to be able to say, "You know what? That's not my specialty, but I'm going to help you find somebody who knows it. Let's look up resources together" or "Let's do something where we can look at a way to get you help because it's not me who can help you," and that can be from a friend or a confidant or a family member or a doctor.

So, again, it's, but I'm putting the burden on the patient. But I'm basically saying you have to keep pushing until you can get someone who can help.

Rae: You so rarely hear a doctor say, "We don't know."

Catherine: Yeah.

Rae: "And we don't like to not know."

Catherine: No.

Catherine: So, I really appreciate that. I also feel like one of the things that I hear in that that is really helpful is kind of this thing like you were talking about like, find people who can help you. It doesn't have to be a doctor, but you might need someone to say, you know, tap your partner, tap your best friend, say, "I can't do this right now, but I have to keep going because I need help. Can you make the phone call? Can you help me find the people who can actually get me the treatment that I need to feel better? Could you watch my kid for an hour so I can shower?"

All these little kind of things. It sounds like to me, finding the support you actually have and doing your best to take advantage of that support is incredibly important. Even more so if you have ADHD, because there are going to be things that you can't do. And I speak from experience. There's so much that like, you know, I remember vividly realizing that every system that I had built that was making my life functional had crumbled into dust and was like under a pile of dirty diapers. And I was like, OK.

Catherine: Now what?

Rae: Well, now what? I guess I'll sit in this chair and cry. Seems like a totally reasonable option for my day. And I'll just hold my baby and look at her and wonder what happens if she stops breathing. So, you know, I think that thing where it's like you acknowledging that you can't do it and then saying like, "OK, I need someone who can."

I really like the idea of just keep going. And if you can't make the call, if you can't reach out, if you can't do the scheduling, if you can't get yourself to your appointment, ask somebody to help you get there, make the phone call, do all these things because otherwise you kind of just wait it out. And that doesn't always work.

Catherine: No. And things don't always resolve on their own. It may just be chronic and then it gets worse and then it gets harder and then it blossoms into something else. And so, yeah, treatment, identifying illness, getting it treated as swiftly as possible, you know, and finding help is, you know, the sooner the better. So, I think motherhood, having a baby, right? There's that liminal moment between you weren't a mother and you are a mother, right?

In that split second that that kid comes out, however they do it or you become a mother through adoption or whatever, there is that moment, your world becomes something else. And so, to your point, all the systems with all your best efforts that you've set up because you have ADHD and you've needed to live your life a certain way so that you can manage it, right? You've kind of created from behavioral parameters.

Yeah, that was for you and you alone potentially. Or how you get through your life or your, you know, how to go to school or how to do this thing. And when you have a baby and you add that into the mix, lid blown off. And I think that that's just not...who's thinking about that before they have a kid?

Rae: Can you think about it? Like, this is something where I never know. Like, could you possibly imagine what that's like when you have an experience? I genuinely am not sure.

Catherine: Well, I don't know. I, you know, it's sort of one of those things like you can't know what it's like to have a kid till you have a kid. True. But can you prepare for it? I do think you can, if you're open, and if you're proactive, and if you can figure out who to ask and what to do. And I don't mean to say if you're not, you know, shame on you.

But I do think that there are things you can do to prepare, which is, you know, am I going to...Do I want to stay on my ADHD medications in pregnancy? Can I be on less? I need help. There's a lot more to say there, but I'm off on 50 subjects.

Rae: Well, welcome to a podcast by people with ADHD.

Catherine: Well, I fit right in.

(21:07) Medication and pregnancy

Rae: One other thing I wanted to talk about with Catherine that I think is really shocking for a lot of pregnant people with ADHD is that you can stay on your medication while pregnant and when you're breastfeeding. The same goes for antidepressants, anxiety medication, the list goes on. Of course, this is person-to-person. Of course, it's something you should talk to your doctor about.

But just the knowledge that you don't have to completely give up the things that have been helping you was revelatory to me. And of course, like so many other things, the reason that there's so much confusion around this is there's just not that much research on women.

Catherine: You know, I do a lot of talks and lectures for medical students and other organizations talking about medications and pregnancy. That's really my, has been my academic specialty. And again, not that long ago, we were saying "If you didn't need it, don't take it." But more and more data has come out looking at the effects of these medications, certain stimulants in pregnancy and postpartum. And so, we have a better understanding.

I wouldn't say we have the kind of evidence we have for the antidepressant medications, which, again, I was like, when I started doing this, we had, there were like six seminal articles and one was like a meta-analysis. There was very little. And now there's just, you know, tens of thousands of articles looking at all of this. I would say generally the ADHD medications have been looked at from a perspective of abuse, stimulants, and the like. But now there is much better data to understand kind of where things are in terms of efficacy and relative safety.

We never say absolute, but I want to digress for two seconds on my soapbox about the fact that when you're thinking about a medication, whether it's a stimulant for ADHD or an antidepressant for depression or anxiety, it's a risk-risk analysis. We used to say risk-benefit.

But really it's a risk-risk because you have the potential risk of that medication to the fetus, to the mom, or to the to the breastfeeding infant, or you have the risk of not treating the mom and what that means for the fetal environment, right? And for the postpartum person and the breastfeeding mom. So, you have a risk no matter what. It's just your choosing...you have to make an informed decision about meds versus illness.

Rae: That is, I think, a very reasonable way to put that.

Catherine: Right. So, there's always a risk. It's just, you get to make...what I love about what I do is I get to help women make choices that they think they don't have.

Rae: That's a beautiful thing to be able to do. Because I feel like...

Catherine: I love what I do because I can always help people think about something in a new way and then make an informed decision. And I don't it's not for me to make it. I may make a different decision. I may not agree with what they do. It doesn't really matter. I'm going to give them the information when I talk to them about what knowledge we have on the subject, and they're going to pick their potential risk. But no decision is risk-free if you have an illness.

Rae: Yeah. I mean, the idea that there is something that can help.

Catherine: Yeah.

Rae: And it's out there and the, of course, like you say, there is not anything where there's no risk, but it is likely to be beneficial and help you navigate one of the hardest times that you will hopefully experience and give you the power to like figure out how to build the systems that are going to help you as you go through motherhood, as you go through postpartum.

I remember once hearing you say that postpartum is kind of like a sort of like a binary state. There's like before and then there's afterwards. That stuck with me and has been very helpful.

Catherine: Yeah.

Rae: But, you know, the idea that you don't have to have this level of like white knuckle suffering is something that we don't really offer to women. That's it. I think almost anybody that thing where it's like your world changes so completely and you have to develop a completely new map for how to navigate your life. And if you have ADHD, that is a harder map to build most likely.

But what you're saying to me is build it and however you build it, that's the right thing to do. As long as you're continuing to build and you're taking care of yourself, not just your baby and you're thinking about yourself as somebody who deserves to be happy, to be able to function in their life, to take the medication if they need it, to get the support that they're supposed to get. And of course, acknowledging as we keep doing that, that's not equally available to everyone all the time.

Whatever you can do within your realm is essential and that it's not, I think, you know, people always use that expression of the like "Put the oxygen mask on yourself before your child," which I think is a little tired now, but like it is a thing like you often feel kind of bad for taking care of yourself, especially as a women. And I think women with ADHD, or in my experience anyway, I find that I wanted to be so much better than I was because all my life I had struggled to achieve like anything.

And here I was. I was like, "I'm going to ace motherhood. I'm gonna be great at this. Like, I got the car seat, I got the little suit that they sleep in where they look like a blue starfish. I got, like, all the little things you're supposed to have and I'm going to do this."

And then to be like, so down and so, like, completely less functional than I'd ever been was a genuine shock to me in a way that I think is hard to convey to somebody who has experienced it or even like amongst people I know who also experienced postpartum depression, people who did or didn't have ADHD, it's like a hard thing to talk about because it feels like you're like screaming up from the bottom of a well, kind of.

Catherine: It seems crazy. But, you know, hopefully that you're not alone. And there are resources, that someone notices that you're not OK. And this is a lot about what we talked about in our book, "What No One Tells You." And, you know, it's really, it's really hard. Period, end of story. I think motherhood is challenging and in the best of circumstances. And anyone out there who tells you it's anything, it's only bliss or it's only anything is not telling the truth. I think it's multifaceted.

And I think when you have a psychiatric illness, you know, or you struggle, you know, with ADHD, anxiety, the gamut, it's that much harder. And I think that the fact that you can get treatment and like you're saying, it's not equally available to everyone, as it should be, but hopefully, we keep doing better and better.

We can help people be well or be at least at a baseline that is well enough that they can get through pregnancy, that they can enter into the postpartum and transition to motherhood and deal with the challenges that exist if you have, you know, in the best of circumstances. Yeah. And that's to me fairly ideal, right?

Rae: Yeah. I mean I think as you say, sometimes you're choosing between risk and risk and doing the best that you can with the things that you have at your fingertips, that is the best choice you can make.

Catherine: That's as good as it can get.

Rae: Thanks for listening to this episode of "Hyperfocus." If you have any questions or ideas for future topics, write me an email or send a voice memo to hyperfocus@understood.org.

"Hyperfocus" is made by me, Rae Jacobson, and Cody Nelson. Our video producer is Calvin Knie. Our music comes from Blue Dot Sessions and Justin D. Wright mixes the show. Ash Beecher is our supervising producer. Briana Berry is our production director and Neil Drumming is our editorial director.

This show is brought to you by Understood.org. Our executive directors are Laura Key, Scott, Cocchiere, and Seth Melnick. Understood is a nonprofit organization dedicated to empowering people with learning and thinking differences like ADHD and dyslexia. If you want to help us continue this work, you can donate at understood.org/give.