Anna Hanel stopped on the Echo Lake trail, sat down on a rock, and told her husband and Ivy, her infant daughter, to just leave her there. “I don’t want to deal with this,” she said, meaning every word. Hanel knew the signs of depression, and on that mountain near Idaho Springs, she recognized that her depression had gotten out of hand. Even so, for Hanel, like many moms, recovering from postpartum depression proved as much of an uphill battle as that 2015 hike.
Now the Lakewood mother of two serves as a patient consultant for Alma, a novel peer-mentorship program at Kaiser Permanente designed to help women suffering from perinatal depression, which comprises both prenatal and postpartum depression.
Depression, explains Hanel, feels like “you’re just walking through four feet of mud” to accomplish everyday tasks, even if you look composed on the outside. The “half in-body” sense of lethargy and sadness that hit her on that trail wasn’t unfamiliar; Hanel had first gone to a therapist (and then a second and a third, to find the right fit) for depression around a decade ago, after a friend pointed out that she’d see a doctor for a stomach bug and ought to do the same for her mental well-being.
Hanel's postpartum depression became pronounced when Ivy was ninth months old, and then she suffered from prenatal depression halfway through her second pregnancy. During these times, Hanel, who'd left her job as a journalist at Colorado Public Radio to be a full-time parent, couldn’t find the energy to do anything beyond caring for her child and her home.
Taking care of her colicky first-born meant a lot of sitting, watching endless episodes of Gilmore Girls so that Ivy could fall asleep in her arms; Hanel didn’t have many chances to leave the house, and her mental health suffered because of it. When she confronted the possibility of postpartum depression after the Echo Lake hike, Hanel emailed her OB-GYN, who said it couldn’t be postpartum because it was too long after Ivy’s birth, and instructed Hanel to turn to behavioral-health programs instead. But Hanel says that, depressed, she didn’t have the wherewithal to follow up, so she kept on “muddling through” each day. Instead of seeking a counselor’s help, she found that making care baskets for refugees through her Lutheran church and doing some freelance work slowly helped her get out of the rut.
While expecting her second child, Charlie, Hanel would cry over feelings of hopelessness, but she kept her mental state mostly to herself, not wanting to burden her friends; she was also reluctant to increase her antidepressant dosage while pregnant. At a five- or six-month prenatal check-up, she cried through the appointment; her nurse practitioner tried to locate the clinic’s behavioral-health specialist, but she wasn’t available.
Public-health leaders widely regard the field of mental health as understaffed, and Hanel had slipped through those cracks.
Eventually, Hanel made it into a Kaiser therapist’s office for three sessions; they helped. Now, even though Charlie, a happy baby, hasn’t let her sleep more than four consecutive hours for the better part of a year, she’s in a steady place. But when a survey about a new pilot program designed to support women through perinatal and postpartum depression appeared in her in-box in February 2017, Hanel thought, “That would have totally helped me,” and asked if there was any way she could chip in.
So Hanel became one of the mothers in the Kaiser Permanente system who are turning their experience with postpartum depression into practical advice that's shaping Alma, a program designed by University of Colorado Boulder Associate Professor Sona Dimidjian, herself the mom of a fifteen-year-old.
Dimidjian is a psychologist with an interest in family care that dates back at least to her undergrad years at the University of Chicago, where she delved into psychology and volunteered at a residential home for children with severe emotional or behavioral issues. As she ascended through the professional ranks, she continued to notice a lack of support for family health and a mental-wellness system that was “really inaccessible and impenetrable,” she says.
Dimidjian settled in Boulder, all the while retaining her focus on family mental wellness. Eventually, she realized that her work training lay counselors in India and maternal-care providers across the U.S. to support others’ mental health had implications for Colorado, too. “We have the exact same needs right here in my back yard,” she says. In 2016, Dimidjian sent a grant application to the National Institute of Mental Health, and the result was the Alma program.
The basic thrust of the project, which is being implemented in Aurora as well as Garfield County with the help of the National Mental Health Innovation Center, is this: Dimidjian and her collaborators — project manager Jennifer Boggs and Arne Beck from the Kaiser Permanente Institute for Health Research — connect women experiencing perinatal depression with other mothers trained in a peer-mentoring approach that integrates skills from a therapy model known as behavioral activation. The underlying idea behind both behavioral activation and Alma is that “you can change how you feel by changing what you do,” Dimidjian says.
The program is backed by prior studies showing that additional counseling by lay counselors (as in India) and behavioral activation (as delivered by clinicians in Colorado, Georgia, Minnesota and Washington) helped patients recover from depression more than the usual course of treatment alone. During Alma's year- to year-and-a-half-long trial run, five peer counselors trained in behavioral activation will call depressed mothers-to-be for six to eight 45-minute sessions, during which they’ll draw on their own experiences and encourage women to set goals, identify activities that might be emotionally healthy, and break down unmanageable-seeming activities into baby steps. By “layering in another level of mental health,” says Dimidjian, Alma is built to address the shortage of mental-health and well-being resources.
The goal is to help mothers find recovery or remittance from depression. This recovery is invaluable, Dimidjian explains, because it means “I can be the kind of mom I want to be.”
Alma’s approach of combining behavioral activation (which has been around, in one form or another, since the 1970s) with peer support for mothers breaks new ground. But while its focus on changing one’s contexts and behavior can help some individuals move past their depression, Dimidjian is clear that it “doesn’t mean that changes in activity somehow cause depression.” And, she’s quick to explain, “this is not just telling people to get busy or just do more.” In other words, it isn’t a wand-waving solution to a mental-health problem.
Personal experience is the program’s backbone. Alma’s been vetted by focus groups and patient consultants like Hanel. The five peer counselors, who are receiving their behavioral-activation training through a web-based platform and video conferences that allow them to participate from home with their children, also dealt with perinatal depression. Such firsthand experience is critical, because being open about one’s sadness during a time that’s purported to be idyllic can be difficult, says Dimidjian, especially when 22.4 percent of Colorado mothers do not receive information about postpartum depression, according to data from the Behavioral Risk Factor Surveillance System.
“I just felt really blindsided,” recalls Firestone mother Alicia Nelsen, another Alma advisor, who grappled with severe postpartum depression and anxiety starting three months after the birth of her son, Peyton. She felt constantly racked with worry that something horrible would befall Peyton and wondered whether becoming a mother had been a grave mistake. But the possibility of depression hadn't surfaced during her OB-GYN appointments, so she wrote off her unhappiness as temporary baby blues.
“You think it’s rock bottom, and then it just gets worse,” Nelsen says. When her general practitioner brought up the possibility of postpartum depression, Nelson dismissed the idea; she thought it was insomnia, and tried different medications to help her sleep. She also tried an antidepressant, but quit taking it after three weeks, concerned about side effects. A month later, however, she found herself in the ER after suffering an anxiety attack. And the next time she visited the ER was when her husband, Randy, called 911 after she’d intentionally overdosed and, still conscious, told him what she’d done.
The day after her overdose, Nelsen told Randy that she felt like she might hurt herself again; he drove her to urgent care, desperate to find a way to make her feel safe. It was the weekend, and she was told she could see a psychiatrist in eight to twelve weeks. The doctors on call didn’t seem to understand her situation: “So you can’t sleep, so you want to hurt yourself?” she remembers one asking, then adding, “That doesn’t make sense.” Nelsen, like many women with postpartum depression, felt her mental-health concerns weren’t being taken seriously, and by the time she was on the phone speaking with a crisis counselor, “I just wanted to leave,” Nelsen says.
While her husband, who had never experienced mental illness himself, didn’t fully grasp what his wife was undergoing at first, he was supportive (their spouses' support, Nelsen and Hanel both say, were critical). Nelsen finally committed to seeking help when she saw a text message from Randy on her mother’s phone, saying that he knew that God would take care of their family, but he was worried about leaving his wife alone. That text drove it home: Her mental health was affecting not just her, but also her family.
Nelsen began therapy and committed to four weeks of medication (therapy without antidepressants, she says, was like “trying to swim without a life raft”). Through it all, her primary-care doctor continued to call every week, ending each call by saying, “I won’t give up on you; I need you to promise you won’t give up.” Finally, eight to nine months after Peyton’s birth, Nelsen got a consecutive six hours of sleep and felt that she was doing more than just surviving each day.
Today Nelsen has a tattoo that reads “I loved you at your darkest” and shares her story as part of various maternal mental-health projects, including the Alma pilot project. The Alma focus groups, she says, involved a “lot of tears and lots of hugs.”
The feedback that Nelsen, Hanel and other mothers offered helped mold Alma into its current form. “Their voices are deeply woven into all of this,” explains Dimidjian, and that mother-to-mother experience and solidarity can make all the difference.
“Feeling alone means you don’t have any hope,” remembers Nelsen, “but when you have that little bit of hope, it can change anything.”