After falling into a deep depression following the birth of her first daughter, Teresa Reis, a psychiatrist and coordinator of the Matter Project, turned perinatal mental health into a life mission. Nowadays, among many other things, she coordinates the Matter project, funded by the Calouste Gulbenkian Foundation as part of the Growing Minds initiative.

Teresa Reis talks openly about the subject, about how many women are estimated to suffer from this illness in Portugal, about the common feelings and when it’s time to ask for help, about the shame, the impact that the mental health of mothers has on the health of their babies, the answers that are available and the enormous work still to be done “so that children grow up to be happy and become productive citizens”.

Is mental health not discussed enough in Portugal?

In recent years there has been more of a debate. One of the few advantages that Covid may have brought was a greater focus on mental health and care needs in this area. The issue is that there are still a lot of problems regarding access to services. The demand for help is growing, but in some parts of the country there is clearly little access to psychology, psychiatry and other types of counselling.

How many women suffer from mental illness in Portugal?

The precise number of women with mental health problems in Portugal is not known. But we do know that around 30 per cent will develop mental illness in the perinatal period, i.e. in pregnancy or the post-partum stage. And if we’re talking about women with a history of mental illness – which doesn’t have to be serious, but a previous episode of anxiety or depression, for example – the likelihood of the illness worsening or recurring is around 60 to 80 per cent. So, without a doubt, it’s a problem that makes this a priority in terms of health intervention.

There’s a lot of talk about post-partum depression, but perinatal mental illness is significantly broader than that…

Post-partum depression is just one of the mental health problems in the perinatal period and, in fact, it’s not even the most common.

During this period, there is a greater likelihood of developing most mental illnesses. In addition to depression, the perinatal period is also a time when you’re more likely to develop anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder, or even more serious illnesses such as bipolar disorder or perinatal psychosis.

What is the reason for such a high prevalence at this stage of a woman’s life?

The reasons are multifactorial. On the one hand, women’s brains do change during this phase; there are neurochemical changes in the brain, a bit like what happens in teenagers, which allow for brain plasticity so that they can adapt to this period of challenges and change, but which can also make them vulnerable to the development of mental illness. This is an immutable factor. Then there are social and community factors, which have to do with social expectations of what is supposed to happen during this period. And here, a society that is very focused on goals, on ‘doing’, ends up being more punishing and more likely to precipitate some of the anxiety associated with being a parent these days.

There are also internal factors – what mums and dads convince themselves they have to be, that they have to be able to do, what they hear on social media, which is often unrealistic and prepares them very little for what is going to be an experience of total lack of control, which is a challenge to their emotional stability.

Is the prevalence of mental illness higher in first pregnancies?

First pregnancies are always a huge challenge. It is often felt by mums and dads as a realisation and an absence of control that is very difficult to integrate.

In terms of neurochemical and cerebral changes, this is also often the very first experience a woman will go through. So it’s often at this time that she has a recurrence of a mental illness that she may have had as a teenager, which leads to a diagnosis, for example, for the first time.

In a second pregnancy, the person is already better prepared, not just for looking after the baby, but because they know what’s going to happen to them emotionally.

What are the most common feelings? What should a woman look out for?

What is most normal is for a woman to sometimes feel confused, lost and unsure of her identity as a mother that has come to stay. There is also an emotional fluctuation that can occur, especially in the first few days after giving birth, which can include easy crying, irritability and insomnia. But it’s very important to realise that these changes, even some adaptive emotional distress, are only normal for a few weeks. Afterwards, it’s important to know how to ask for help.

What should you pay particular attention to? When do you draw the line?

It’s not normal to stop sleeping altogether. It’s not normal not to be able to switch off from your baby, to be constantly hyper vigilant, worried and afraid that something is going to happen to him. It’s not normal to cry all the time. It’s not normal to feel sad. It’s not normal not to have an appetite. It’s not normal to have a constant feeling that you’re not a good mum and that you don’t meet the needs of what you had imagined would happen in the post-partum period. If this happens, these thoughts and emotions need to be shared and you need to ask for help.

Is social media helpful or harmful?

Overall, I’d say they don’t help. But you can find anything on social media… While on the one hand they may have played an interesting role in providing more insight into the difficulties of motherhood, on the other, there is often a normalisation of suffering and of what may in fact be mental illness.

Most of what we find on social media is idyllic information, rules, guidelines, easy solutions, when nothing about parenthood is easy, nothing about parenthood works for long, there is a need for constant adaptation and flexibility that can’t be sold as an easy solution.

But if everyone is there, it’s a very interesting opportunity for those who have some responsibility for mental health literacy to get information out there for women in the perinatal period. The 25 to 40 age group uses social media a lot and women in the perinatal period, who are at home with their babies, often use it as a cognitive distraction, a way of disconnecting from some of the difficulties and even their own loneliness.

How should you handle it if you spot warning signs?

There is no other stage of life during which women have so many appointments, so many contacts with health care professionals. But most of these resources are not geared or prepared to respond to women’s emotional needs at this stage. So even though women have six to eight consultations with their family doctor, there is rarely room for discussing things like ‘I’m more tired’, ‘I’m not sleeping’, and very often the answer will be ‘it’s the body getting ready for the baby to be born’, which is a fallacy, a completely wrong myth.

There is such easy and even standardised access, and surveillance is so close, that this is an opportunity that is being missed. It would be good if we could take one of these opportunities and say ‘ok, my blood pressure is fine, my blood sugar is fine again… today I want to talk about the fact that I don’t feel well, I feel sad, anxious, I don’t sleep, I don’t eat.’

We need global perinatal mental health literacy, we need families not to downplay and minimise what are not only adaptive complaints, but already signs of mental illness.

Is it shameful to talk about yourself when you’re carrying or have just had a baby who needs all your attention?

No one wants to be unwell, let alone with a mental health problem, and even less so in the perinatal period, which is still considered a golden, happy time, when you fulfil a social role that you’ve aspired to and prepared for. So, obviously, the failure to fulfil these expectations is often associated with suffering, shame and the dragging out of situations that might not have happened in another period. ‘Everything is going well, here’s the pregnancy I wanted, here’s this beautiful baby, here are the people around me saying they don’t understand why I feel the way I do and, obviously, this increases my guilt, my shame and my struggle to look for help’.

What impact does the mental health of a pregnant woman have on the mental health of the child?

A woman who is pregnant or has a baby, when she is ill, is not ill alone, she is part of a dyad and, obviously, what happens to her will have consequences for her baby.

What we do know is that the children of parents with mental illness can be up to 13 times more likely to develop mental illness. So when we’re talking about mental health in the perinatal period, we’re not just talking about the woman’s health, which is obviously very important, and which deserves, has the right, to be properly addressed; we’re actually talking about the mental health of the mother-baby dyad, the consequences that this illness will have on this baby and on the whole family structure. The likelihood of illness increases in the baby, in the partner and therefore, once again, it is absolutely essential that perinatal mental health care is a priority.

Very little is said about men at this stage…

But mental illness in the perinatal period doesn’t only have a peak incidence in women. It also happens to men. They’re also there, they’re also experiencing these difficulties, they’re also going to have to integrate a very important identity change that will change their meaning as a person, their place in the community and all of these are factors that can precipitate the development of mental illness.

Now, if it’s difficult for a woman to ask for help, it’s much more difficult for men.

What led you to work in this area, in perinatal mental health?

I am a survivor of perinatal mental illness. I had very severe depression when my eldest daughter was born. I was actually dying, I was really ill. And I was already a doctor, I was doing my internship in psychiatry, I had lots of psychiatrist friends, lots of psychologist friends, my parents were doctors… and nobody helped me.

Did nobody see it?

Maybe they saw it, but they didn’t know what they were looking at.

I had all the signs, I was deeply depressed. At a certain point, I didn’t want to live any more. And it took me a while to realise what was going on and to realise that it wasn’t the fact that I was having a baby, which brought a lot of change to the life of a successful woman, who was a doctor, who was doing a PhD. It was not just that, it was that I was ill. And when I finally realised that ‘this isn’t normal, this isn’t me, something’s wrong’, I started looking for therapy, then I realised I had to take medication.

And when I got better, I realised that… ‘If this happens to me, being in this place of enormous privilege, I wonder how it’s going to affect most women. What kind of dark, helpless place will they be left in?’

At the time [seven years ago], there was no training available in perinatal mental health in Europe, so I ended up doing my first training in the United States where, fortunately, I made a lot of friends who encouraged me to make tackling this problem a life mission. It also led me to implement, for example, one of the first organised screening and intervention programmes in a public service in Portugal. It’s still one of the few nationwide programmes like this in the SNS (NHS), which is responsible for the majority of the population in Portugal.

Were you able to implement the programme?

Yes, we did implement this programme, which has now celebrated more than 5,000 interventions, with extremely scarce resources. It only has the results it has because of enormous dedication and because we truly believe that this is a phase where women, families, fathers, pregnant women and babies need a lot of attention if we really want a fairer and more equitable society in the future. After all, that’s also what we’re talking about when it comes to perinatal mental health. Because when the poorest, the most vulnerable don’t have access to care, we’re fuelling a vicious circle of illness and poverty which families find very difficult to get out of.

This turns out to be the embryo of the Matter project, supported by the Gulbenkian Foundation…

The Matter Project was born out of a desire to do more than what we were already doing at the hospital.

We already had an organised perinatal mental health programme, with screening and intervention, but we weren’t getting to all the women. To help us reach all women, we had to be active in the community, in primary healthcare, where most women have access to low-risk pregnancy surveillance.

We wanted to put perinatal mental health on the agenda of the woman or pregnant person, but also on the agenda of the health professionals working with these women at this stage of their lives. The Calouste Gulbenkian Foundation has enabled this to become a reality: the pilot project is providing training and allowing for an intervention that will hopefully reach all the women in Central Alentejo.

You want pregnancy to be approached with a multidisciplinary approach that goes beyond genecology-obstetrics and looks at the person as a whole and the family as a whole. Is that it?

Absolutely. Basically, what we need is to look not only after the health of the baby, but also at the physical and emotional health of the pregnant woman or person. If the physical and mental health of the pregnant woman or person is not well balanced, the health of the child will also be affected.

When we can get health professionals to focus not just on the baby, but on the woman and how she’s doing physically and emotionally, we’ll be able to achieve greater results in terms of prevention and health care promotion in general.

What results do you hope to achieve with this project?

On the one hand, the training of health professionals. That we get all the professionals involved in the perinatal period – doctors and nurses, but also social workers, CPCJ professionals, court liaison teams, EMATs, CAFAPs – to speak the same language. On the other hand, ensuring that there is screening during pregnancy and the post-partum period and that, following this screening, professionals have very clear guidelines on what to do if there is a situation of potential mental illness.

Is it possible to quantify the benefit for the SNS of this type of intervention?

If we wanted to, we certainly could, because if we have costs associated with the disease, we should also be able to quantify the economic benefit and cost-effectiveness of perinatal mental health programmes. However, we’re talking about programmes that aren’t implemented in one or two years.

We’re talking about behavioural changes rather than programmes, and these take time and require guidance and unity. And in health in general, let alone in mental health, we can’t make an assessment if we don’t have time to evaluate. We would need to invest in the programmes now, and then be able to assess the children who have been intervened. This alone means perhaps 10 years of evaluation using the same guidelines. Unfortunately, in Portugal we’re not seeing much of this.

In England, there are many studies that show very significant benefits. Any disease, if not treated properly, progresses. So not only do we have the benefits of a treatment that will allow these women to return to functionality more rapidly, but we also have a very interesting effect on subsequent generations. The investment made in the perinatal period has a very significant benefit: in addition to working with mothers, we’re also promoting the children’s mental health, preventing difficulties in their development and ensuring that they grow up to be happy and become productive citizens.