How The VA Healthcare System Can Help Pregnant and Postpartum Veterans pt.2

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Yesterday I wrote part one of my experience with the Department of Veterans Affairs mental healthcare system as a pregnant mother and veteran, giving my initial suggestion as to how they can improve their quality of care. You can read it here, and the rest of my story and suggestions below. 

IMG_4393Invest in Specialists and Training

My initial psychiatrist at the VA was woefully uninformed on the current research on maternal mental health, and medication use during pregnancy. As I said yesterday, once they decided to continue to treat me, the closest they could get to an “expert” on reproductive psychiatry was a psychiatrist on staff with a background in pharmacology.  While she was an improvement, I still had to point her to books and other resources online that contained up to date information. (For example, she had no idea books like Pregnant on Prozac or websites such as MGH Center for Women’s Mental Health existed) Unlike my OB, she was unfamiliar with the work of experts like Dr. Marlene Freeman, Dr. Lee Cohen, Dr. Karen Kleiman, and many others. When I was 8 weeks postpartum my care was transferred to yet another psychiatrist, who was in disbelief that I was actually breastfeeding my son while taking medications. She was also woefully uniformed and readily admitted she knew very little about postpartum mood disorders and methods of treatment, and would be deferring to her supervisor for help in my case. This was not only disheartening, it destroyed my confidence in the VA’s ability to manage my mental health care. Women veterans need mental health care professionals who understand the nuances of maternal mental health, informed on current guidelines and research regarding medication use, and trained on how to address the particular needs of women during pregnancy and the postpartum period. Reproductive psychiatrists should be hired and if it’s not feasible to have at least one on staff at every mental health clinic that sees the female veteran population, then there should at least be a team of these specialized psychiatrists professionals at local clinics can consult with for guidance and input on a case by case basis. Every psychiatrist and therapist employed by the VA should also receive some form of training specific to maternal mental health. I do know that the VA does indeed have a few experts on staff at clinics in places like Chicago and Dallas, but they simply aren’t enough. We need more.

Give Pregnant and Postpartum Veterans Scheduling Priority and Appointment Flexibility

I called the last month to try to speak with my psychiatrist. I was noticing a shift in my mood and was beginning to struggle a bit and wanted to reach out to her for treatment advice and support. I was told she was unavailable and that I should make an appointment. Her next available appointment? December 8th. When I was roughly 4 weeks postpartum, the maternal outreach coordinator called and screened me for postpartum depression, which I was extremely grateful for. However, when she went to put in a consult for me to be seen and have my care transferred to a new psychiatrist, it took another 6 weeks for that consult to go through…and we both had to make several follow-up calls to ensure it was being pushed through the system. I saw my new psychiatrist and talked with her about how I was doing at 8 weeks postpartum. I was then told my next appointment wouldn’t be for another 4 months because of the schedule rotation they had in place. A new mom’s first year postpartum is a critical time. Pregnant and postpartum veterans should have top priority in getting appointments with their providers, because not only does it support and enhance their mental health, but it supports and enhances the health of their newborn as well. Having the right support and access to treatment gives mothers and their new babies the strong starts they need to thrive-they should not be a the mercy of an overcrowded system and providers with heavy case loads.

Flexibility with appointment scheduling would help significantly as well. I was able to convince the therapist I saw very briefly during my pregnancy and my psychiatrist to have our appointments over the phone instead of in office because it was easier to ensure I’d be back home in time to pick my older two children up from school. My schedule was also packed with pediatrician visits and therapy appointments for my older two children, and the VA’s appointment availability wasn’t very accommodating to that either. Also-why not offer daycare services? I have to take my baby (and older kids if they aren’t in school) to every appointment with me, where it can be quite difficult to focus on informing my psychiatrist of how I’m doing, and what I need.

Support Groups and Talk Therapy

Since moving to Austin and enrolling in the VA mental health care system here in Central Texas, it has been nearly impossible for me to acquire talk therapy with a therapist who understands the particular needs and concerns of a woman and mother, as well as a peer-to-peer support group I can attend. After several starts and stops, I finally talked with the head psychologist at the mental health clinic here in Austin last Spring. She was earnest in her desire to offer me some kind of support that worked with my schedule and their available resources but she had to admit that there was very little they could do to help a woman in my situation. “We just don’t have the resources for your particular needs; all of our support groups are co-ed and we currently don’t have a therapist on staff with the right kind of training or experience that would benefit your particular situation. We’re trying to find a way to create it, but unfortunately there isn’t a lot we can do right now.” Mothers need support, especially during their first year postpartum. Either the VA needs to find a way to develop and provide it or agree to outsource it to a civilian provider like they do prenatal care and help the veteran cover the cost, if not cover it fully themselves. Many women’s health clinics currently have breastfeeding support groups for veterans who are nursing. I don’t think it’s out of the realm of possibilities to create a group that supports our mental health as well.


This experience has taught me a lot about the ups and downs of having the VA manage my mental healthcare as a pregnant and postpartum veteran. Strides in women’s health have been made over the last decade at the VA, but there is still more work that needs to be done. I’m hoping that sharing my experience exposes a critical gap in care and lends to the demand for change overall at the VA that’s currently taking place. We’ve been warriors for our country, and I hope the VA will honor our service by helping us and our families have the strong starts we deserve.


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How The VA Healthcare System Can Help Pregnant and Postpartum Veterans, pt. 1

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IMG_4403I’m what the Department of Veteran Affairs call a “100% service-connected OEF/OIF disabled veteran.” As such, I am entitled to a host of benefits, the most comprehensive being that of healthcare. When I first separated from the Air Force in 2006, I was a pregnant single mother caught up in the crash landing that is transitioning into civilian life. I spent the last two trimesters navigating unemployment, acquiring social services, and the waiting game every person who applies for disability compensation through the VA does. At the time, the VA’s standard policy was to outsource all prenatal care, cover the costs of labor and delivery, and provide insurance coverage for newborns during their first seven days…but only to those women veterans who were in their system and registered as disabled veterans, regardless of their rating. As a newly separated airman who had just filed my claims, I was unable to utilize the VA healthcare system for my prenatal care and had to apply for Medicaid through the state of Maryland.

Since that time, the VA has made significant strides in expanding the range of services it provides for women veterans, placing an emphasis on making these services more comprehensive in the women’s health department. Now they go beyond just covering the cost of prenatal care and delivery. They’ve hired maternal outreach coordinators who act as a liaison between pregnant veterans and the VA, provide breast pumps for nursing moms, cover the costs of nursing bras and lactation consults, and have breastfeeding support groups for new moms at their women’s health clinics.

The one area where there still remains a significant gap in care, however, is in that of the mental health of pregnant and postpartum veterans. My recent experience as a pregnant and postpartum veteran with the VA healthcare system has been complex. During this last year it was less than ideal; full of starts, stops and dead ends that left me incredibly frustrated and disheartened at times. However, I do believe wholeheartedly that the VA desires to improve their quality of care for women veterans. I’m grateful for the efforts they’ve made to remedy where they’ve misstepped in my particular case. After navigating this system both during pregnancy and over the last 12 months postpartum, I’d like to offer suggestions as to where and how I believe VA healthcare can remove current barriers to treatment and provide adequate, comprehensive care to pregnant and postpartum veterans; particularly those with mood disorders.

Treat Pregnant Veterans with Existing Mental Health Conditions

When I found out I was pregnant, my primary care doctor at the VA outpatient clinic told me to quit my medications immediately and wait for a call from my psychiatrist. I did, and never received that phone call. I instead received an appointment card in the mail two weeks later with a date and time to see her in her office. At that appointment, my psychiatrist told me that for someone in my “condition” (having bipolar disorder), getting pregnant was irresponsible. When I told her I’d like to discuss my treatment options and wanted to know what she thought about my staying on at least my mood stabilizer she laughed and said my only option was to go medication free-anything else would put my baby in danger and cause him irreparable damage. When I raised concerns about my increased risk of relapse due to having bipolar disorder and a prior incidence of PPD, she dismissed them completely. When I told her that my civilian OB (who the VA had outsourced my prenatal care to and who also happened to have extensive experience in treating pregnant women with bipolar disorder) had given me his suggested treatment plan and that it involved me staying on at least two of my medications, she got angry and told me that if I wanted to listen to him, then fine, but she wouldn’t treat me. Two weeks after that appointment I found out she cancelled my prescriptions when I called for refills. I had to go to my OB and request that he provide me with my medications, which he thankfully did. He also called the VA mental health clinic and advocated for me, insisting that they remain in charge of my mental health care.

It went all the way to the Chief Medical Director of the Women’s Health Clinic for Central Texas, who relayed this message to the maternal outreach coordinator who had been trying to help me as well:

 “The VA can’t assume responsibility for anything that may happen as a result of her staying on these medications during her pregnancy. Our psychiatrists are not experts in this area whereas a private obstetrician is. If he says these medications are safe for her to take during her pregnancy and he will write her a prescription for them, then she can bring that prescription to the VA pharmacy in Austin and we can fill them that way. If something were to happen, then this private OB is the one responsible, not the VA. Unfortunately this is what we have to do in situations such as this.”

While I understand the desire to avoid liability, I fail to see how flat out refusing to treat a veteran who’s been in your care is striving to provide the best level of care for a population you’re committed to serving.

As a result of serving in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom), as well as the alarming prevalence of sexual assault in the military, many women veterans suffer from mental health conditions such as PTSD, bipolar disorder, anxiety, and depression.  As such, it places them at particularly higher risks for developing antenatal and postpartum mood disorders should they become pregnant. Refusing to continue to treat these veterans during such a critical time in their lives is negligent and dangerous, as is telling them the best thing to do is quit their medications cold turkey. You cannot leave these women out in the wind to navigate the journey through pregnancy alone.

Eventually, I was assigned to a psychiatrist on staff with a background in pharmacology who agreed to work with my OB’s treatment plan and offer input.


I would love to see the VA do away with such a harmful policy and replace it with one that is collaborative with the civilian providers they outsource care to, as well as guided by current research. My fellow veteran mothers deserve that.

Tomorrow, I’ll be sharing more of my thoughts on this. Stay tuned.

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Triggers and How They Affect Recovery

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Triggers and Recovery from mental illness

Knowing is half the battle. I found this to ring true in my experience with managing my mental illness during my pregnancies and postpartum.

I was diagnosed with Bipolar Type 1 in 2006. It took over a year for me to find the right psychiatrist, the right combination of medications, and the right techniques through therapy to allow me to begin to manage an illness which had taken me and my family completely by surprise. After months of anguish over what was working and what wasn’t, we finally found a medication that stabilized me and I started to feel pieces of my old self emerging from the darkness.

Once I had been stable for about a year, my husband and I decided we were ready to start a family. I was scared of a recurrence of my illness, but wanted to be a mom more than anything, so we started trying and I was able to get pregnant rather quickly. Unfortunately, our joy was fleeting as I experienced an early miscarriage and had to have a D&C. I was afraid that the medication I had been taking for my bipolar disorder caused the miscarriage, so I convinced my psychiatrist to allow me to taper off the med so that we could try again after I healed from the surgery.

We became pregnant again fairly soon after, and since I was doing so well off the medication and had no recurrance of symptoms, my doctor continued to see me as a patient but allowed me to stay off my medication for the duration of the pregnancy.

This was a terrible decision on both our parts, but I didn’t realize this at the time. Four weeks after delivering my son I experienced a severe episode of postpartum psychosis and had to be hospitalized for a week. It was arguably the worst week of my life, having been ripped from my child, having to abruptly stop nursing, and it took an incredible toll on me both physically and emotionally.

I was stabilized quickly by the team of doctors at the hospital by resuming my course of medication I had been on before my pregnancy. The recovery from the trauma of being taken away from my newborn for a week would take much longer.

I learned through my postpartum psychosis episode that my triggers are: lack of sleep and lack of medication in my bloodstream. These two facts would prove essential to me creating a much more positive postpartum experience with my second child. But not without another lesson first.

Once stable again after my PPP hospitalization, my husband and I began to talk about completing our family with one more baby. Even with my three hospitalizations (two before our first child and the PPP episode), I still didn’t know enough about my illness to know that the benefits of me staying on my medication during the pregnancy and exposing the fetus to the medication, although not the most ideal situation, far outweighed the risks of not being on medication at all given this was one of my top two triggers.

Doctors can advise patients, but it’s up to the patient to follow through with the prescribed recommendations. My doctor had agreed to let me stay off medication during the first trimester due to a heart defect risk, but after week 12 we decided I would go back on my medication for the duration of the pregnancy.

Tapering off my medication in just week 5 of the pregnancy, combined with my excitement and mounting loss of sleep over how excited I was to see those two pink lines on the pregnancy test, landed me in the psych ward again. My baby was barely the size of an orange seed and I had to be hospitalized for almost a week and put on antipsychotic medication to bring me down from the mania I had been struck with.

Because of lack of sleep and lack of medication. Two things I learned I could control.

Recovery from that episode took months; experts say that each subsequent episode is more difficult and takes longer to recover from, and I’ve found this to be true. But I emerged from that setback a much more informed and capable mother, ready to truly manage my illness so that it did not cause me and my family any further pain.

My husband and I talked about how we could handle my postpartum period differently with our second child, and we made plans to take charge over my triggers so that I could stay in recovery long-term. I stayed on my medication for the entire rest of the pregnancy and beyond because my medication kept me stable. We made plans that I would bottle-feed and my husband would take over the middle-of-the-night feedings between 2am – 5am so that I could get a long stretch of sleep at night, keeping my nocturnal clock in check.

I’m not saying it was easy. But my postpartum period with my second child was so much more enjoyable and relaxed compared to my first because I took the upper hand over my triggers. With my family’s support, I made it through. And I continue to keep a firm grip on my dedication to the medication that keeps me stable and getting the appropriate amount of quality sleep each night so that I can stay steady on my recovery path.

Bipolar disorder is a condition I’ll live with for the rest of my life. Learning my triggers and techniques which allow me to stay on top of them so they don’t throw me into a manic episode has been a learning process, but it is one which has empowered me to live well even with a mental health disorder.

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6 Ways You Can Be an Empowered Patient During Pregnancy When You Have Bipolar Disorder

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The best person on my care team? My OB. Hands down. When we found out I was pregnant (far sooner than we had planned), my husband and I decided right away that no matter what course of treatment  we decided upon after speaking with my doctors, our number 1 priority was my mental health. Still absorbing the shock, I remember my husband standing in our bedroom with his fingers lacing their way through mine, saying, “Health and wellness, Addye. That’s our focus, ok? Your health and wellness. No guilt, no shame, no matter what happens. YOU and your health are what’s most important. We’ll do whatever it takes. We’ll get through this together. I promise. Let’s do this.”  I’m pretty sure I was fighting back tears and a whopping dose of fear in that moment as I high fived him and agreed: We could do this. I could do this.

And I did. I have. I’ll be a year postpartum next month, and as I watch my youngest son crawl into the room he shares with his two older brothers, I think back to that moment in my bedroom and feel proud of that promise we made, and the treatment option I chose.

Given my previous history with PPD, the nature of my illness, and the increased risk of relapse I faced because I have bipolar disorder, we decided staying on two out my three medications was what health and wellness would look like for me…as well as for the baby and the rest of my family.

That was my choice, but I know many other mothers with bipolar disorder who opted to go without their medications during their pregnancies and remained healthy throughout. No matter what course of treatment you and your care team decide upon, the important thing to remember is that you DO have options. There’s nothing I hate more (aside from stigma) than coming across an article on the internet that gives women with bipolar disorder incomplete information regarding their treatment options during pregnancy and breastfeeding, doesn’t point to what resources they can utilize to make informed decisions, and doesn’t tell them how they can navigate the unique challenges they’re faced with.

So let’s talk about how to do that, shall we? (This post is going to a bit long, but bear with me, I believe what I’m sharing with you is important)

1. Build Your Care Team, Create a Treatment Plan

I cannot stress the importance of this enough: You MUST have people on your medical team who have experience in treating pregnant women with mood disorders. Think of this as your Dream Team. People you want on this team are your OB, your psychiatrist, therapist (if you have one), and a pediatrician. It’s possible your obsectrician will also want a reproductive psychiatrist and maternal fetal medicine doctor on your team as well, especially if their experience on this front is minimal. Thankfully, my OB had extensive experience with caring for women with bipolar disorder during their pregnancies and knew pretty much everything that’s out there regarding medication use during pregnancy and breastfeeding. He was up to date on the latest research available and proved to be my most invaluable resource on my care team. Seriously, he’s the one who gave me the confidence that all would be well, and that choosing to stay on at least two of my medications was a safe and healthy choice. Both he and my psychiatrist spent a lot of time going back and forth, weighing the risk vs. benefit of staying on meds or going without, and although they disagreed on a few minute points, they ultimately decided staying on medication would be healthiest for me, and ultimately, baby.

Also be sure to find a pediatrician to consult. You’ll need one anyway after the baby is born, so you might as well find one who knows about medications, postpartum mood disorders, AND does depression screenings at well visits. (Our pediatrician does and it has been incredibly helpful to me this past year.)

Finally, ensure that the team you build has your mental health as their top priority. As soon as a woman becomes pregnant, the focus tends to immediately shift toward the health of the baby and stay there. In the past, I’ve dealt with OB’s who only cared about how I was doing physically and what impact any physical conditions I had would have on my baby in utero. Not once did they focus on my mental well-being, let alone have it guide my prenatal care. Listen: I completely agree that baby’s health is a priority. I do. But I’m going to just come right out with it and say that a mother’s mental health is what’s most important and should be the foundation of her prenatal care, and if no one on your team shares in that philosophy? They shouldn’t be on your team or in charge of you and your baby’s care. Period. Same goes for the person treating your mental health condition. My first psychiatrist through the VA was woefully uninformed and unhelpful when I told her I was pregnant. It took a lot of pushing, but I was finally able to have my care transferred to a psychiatrist with a background in pharmacology and reproductive psychiatry, and it made a significant difference in my overall care.

2. Communicate and Advocate

Everyone on your care team should be in constant communication with you and each other through every phase of your pregnancy and delivery. They should also be able to come to an informed consensus (with you) about your treatment. There is nothing worse than having two of your doctors at an impasse over a part of your treatment plan because they just disagree. It’s incredibly frustrating and the last thing you need to be worried about. If this happens, don’t be afraid to speak up and advocate for yourself, reminding them that they are there to help care for you and your baby, and you need them to work together.

Always be open and honest with your care team about what you’re feeling and experiencing throughout your pregnancy, so they know how to help you as soon as possible. Part of my treatment plan involved staying off of my mood stabilizer during my first trimester, but remaining on my anti-depressant. At 11 weeks, I called my OB and told him my mood was starting to take a nosedive and I was worried about a depressive episode. He moved my NT ultrasound scan up to the start of week 12, and as soon as he reviewed the results, gave me the all clear to start back on my mood stabilizer.

3. Do Your Own Research, Knowledge is Power

There are books out there on  medication use during pregnancy and breastfeeding and the variety of treatment options available for women in our situation-get your hands on them and read as much as you can, being sure to talk with your care team about what you learn as you do. When researching my treatment options and discussing them with my team, books I read included Pregnant on Prozac by Dr. Shoshanna Bennet, Medications and Mother’s Milk 2012: A Manual of Lactational Pharmacology by Dr. Thomas Hale, and The Complete Guide To Medications During Pregnancy and Breastfeeding: Everything You Need to Know To Make the Best Choices for You and Your Baby by Carl P. Weiner MD and Kate Rope.  I also read everything I could on the MGH Center for Women’s Mental Health blog, which has a wealth of information on research studies and how to use their findings to make informed treatment decisions with your clinician.

4. Create a Birthplan That Takes Your Mental Health Into Account

Initially, I considered going without pain meds for my delivery. I read all I could about natural child birthing methods, and had it in my mind that I’d hypnobirth my way through labor and delivery, even if  I wound up crying uncle and utilizing some form of pain medication. But at 28 weeks, I landed in L&D with contractions that wouldn’t stop without magnesium. In fact, they didn’t really stop the rest of my pregnancy. I contracted every day of my third trimester without ever dilating more than 2 centimeters. Previous experience reminded me that neither of my labors with my older two progressed without intervention, despite having intense, painful contractions that were off the charts for a week. Looking back, I’m positive this contributed to the panic and anxiety I had during both deliveries and afterward. With this third go around, I was miserable, exhausted, starting to have anxiety attacks, and was starting to cycle between nesting induced hypomania and depression.

At week 38 I told my OB I was done and worried that continuing would put me over the edge and trigger a depressive episode-and I hadn’t done all of this preventative health and wellness work to be in a dark place when my baby boy was placed on my chest. I knew my limits, and wanted a bit more control. I wanted an induction. He agreed, and a week later I was in the delivery room smiling and laughing as I stared lovingly at my newborn-100% anxiety free. It was a calm and beautiful experience and in my opinion, gave me the strong start postpartum I needed.

Whatever your birth plan is, make sure it’s flexible, realistic, and compliments your treatment plan.

5. Have a Support Network

Having the love and support of friends, family, and your partner is so important. Lean on them when you need to, and don’t be afraid to ask them for help. Inform them of ways they can be a support to you. My friends (fellow Warrior Moms) and my husband did an amazing job of supporting me during my pregnancy and this past year. I couldn’t have made it without them to call, text, and share this experience with. A therapist can also be an invaluable resource to you during this time; they can help you process all you’re experiencing and develop coping strategies for managing your postpartum period. Consider finding support online in a private forum for pregnant and new moms with mood disorders (like Postpartum Progress’ Smart Patients Forum or the #PPDChat private group on Facebook), or find what’s available to you locally through organizations like NAMI or DBSA.

6. Self Care

Try to find ways to incorporate rest into your day as much as possible, even if you already have other children. Do not go without sleep. Create manageable to-do lists, and reconstruct your expectations about how much you can get done each day-especially if you’re working. Practice deep breathing exercises, and engage in physical activity that is both safe for you and baby and feels good. Engage in activities that are calming and nourish your soul-even if it’s binge watching your favorite show on Netflix. Keep track of your mood either in a journal, or with a mood tracking app on your phone; this will help you be able to communicate to your care team and support network how you’re doing. (I use iMood Journal) Prenatal massage, mani/pedis…whatever self-care looks like and is for you, be sure you do it and do it as much as possible.


I hope this is helpful and gives you a good starting point for creating a plan that works for you. Remember-You have options when it comes to treatment. You can do this. I promise. You got this, mama.

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