Lauren M. Osborne, MD | Vox

A psychiatrist’s defense of Tully, a controversial new movie about postpartum struggles

2018-05-07T10:07:59-04:00

Charlize Theron in Tully. | Focus Features

“I believe that screenwriter Diablo Cody, director Jason Reitman, and lead actress Charlize Theron owe an apology to every survivor of maternal mental illness,” writes blogger Graeme Seabrook in a post titled “Why I won’t see Tully and why you should think twice before you do,” on a motherhood-centric website called All the Moms.

This is just one of many heated reactions coming from the mommy blogosophere about the new film Tully, which depicts a mother struggling with the responsibilities of parenthood after the birth of her third child. Most of the controversy revolves around the fact that the film implies that the lead character, Marlo, beautifully portrayed by Charlize Theron, may have postpartum depression or postpartum psychosis — yet the film fails to acknowledge this explicitly or depict the character seeking treatment.

“I am not sure if this was intentional, or if the film-makers did not realize that the character they created had [postpartum psychosis],” wrote Diana Spalding on Motherly. “I am surprised that they seem not to have consulted with a therapist to ensure that the topic was handled appropriately, whatever their intention was.”

I’m a psychiatrist who focuses on pregnancy and mental health. As an expert on this subject, I was eager to watch the film — and having seen it, I have to ask: Is all this heat deserved? Should we refuse to see Tully because a struggling mother’s illness is not recognized or treated appropriately? Or should we celebrate it for generating this heated discussion and raising awareness about maternal mental illness? I’m inclined to think the latter.

At the core of the controversy around Tully is its twist. To participate fully in the discussion around the film’s depiction of postpartum depression, we’ll need to reveal that twist at the end, so be warned: spoilers follow.

The film opens with Marlo, the mother, at the end of her rope. She’s frazzled by her “quirky” kindergartner, a child with implied special needs who regularly throws tantrums, and the pressure intensifies with the birth of her third child. Her husband plays video games instead of helping with the baby.

There are hints even early on that Marlo is more than just “stressed out” — her brother mentions that her behavior in the past few years has been radically different, saying, “I just want my sister back” — but overall, the beginning of the movie seems to be depicting the universal stresses of motherhood. We see spilled breast milk, dirty diapers, frozen pizza for dinner, and rage, all things to which any tired mother can relate. Marlo’s brother suggests she hire a night nanny.

Things take a turn with the arrival of a young woman named Tully, who we assume is that night nanny. Tully is a charming, helpful, engaging young woman who appears to exist solely to help Marlo. She cleans the house, allows Marlo precious sleep between feedings, bakes cupcakes. But by the time Tully climbs into a waitress outfit and has sex with Marlo’s husband the first time he meets her — and the husband does not seem surprised by this — we realize there is something off with Tully.

One night, Tully encourages Marlo to drive them both while drunk, which ends with Marlo crashing her car. And then comes the twist: When the film shows Marlo alone at the hospital, we realize that Tully is not real. She is an extension of Marlo, meant to represent a younger, less cynical version of herself. It’s that plot turn that has people up in arms.

Does Tully’s plot twist suggest that Marlo has postpartum psychosis?

So what illness does Marlo likely have, and what’s wrong with the way it’s portrayed in the film? Postpartum depression, which affects up to one in five women and is severely underdiagnosed and undertreated, is a devastating illness with long-term consequences for mothers and children.

A depressive episode in the first weeks or months after giving birth is typically characterized by changes in sleep and appetite, low mood, loss of interest or pleasure, irritability, feelings of low self-worth, and sometimes suicide. Anxiety in the period right before or after birth is also extremely common and can be part of postpartum depression or exist without depressive symptoms.

Postpartum psychosis, which seems to fit Marlo’s symptoms better than postpartum depression does, is a much less common disorder, affecting 0.1 percent of the population. Women with postpartum psychosis are sometimes depressed but more often exhibit mania, characterized by decreased need for sleep, grandiosity, and risky behavior, along with psychotic symptoms such as disorganization, confusion, and sometimes hallucinations and delusions.

Postpartum psychosis is often a manifestation of bipolar disorder and is much more common in women with preexisting bipolar disorder than in the general population. It is considered one of the few true psychiatric emergencies, in large part because of the high rates of suicide (5 percent) and infanticide (4 percent), and it nearly always requires psychiatric hospitalization.

Both disorders, if recognized, respond well to treatment, but in many cases they are not recognized. This happens because we don’t talk enough about mental illness in this country. What’s more, the media and the public at large tends to describe and depict motherhood as a glowing and happy time. Women who become ill are often ashamed that they don’t fit this model — and family members often chalk up serious symptoms to “normal” new motherhood and sleep deprivation.

Once we know that Tully isn’t real, some of the movie’s earlier plot points take on a distinctly different tone. The clean house and exquisitely decorated cupcakes weren’t the product of work done by an employee while Marlo slept but were things Marlo did herself, staying awake all night and frantically cleaning and decorating. That, alongside the impulsive drunk driving incident, makes me think that Marlo is probably manic. The idea that Tully is a hallucination, which is likely given that Marlo discusses her as if she’s a real person, is consistent with a diagnosis of postpartum psychosis.

In starting a conversation about postpartum mental health, Tully is doing a service

So is the film using serious health issues as a cheap plot twist? I don’t think so. It depicts one woman’s experience — and those of us who treat maternal mental illness know that no two mothers are alike and no two illnesses are the same. Hallucinations of postpartum psychosis do not usually take the form of benign, lighthearted helpers, but that’s not to say that they couldn’t.

The bigger question seems to be if the movie has a responsibility to recognize and name what this illness is and, as some have suggested, to show Marlo getting treatment. “As a Certified Nurse Midwife, here’s what I wanted to see next,” wrote Ann Smith in a statement for Postpartum Support International, a wonderful organization that has done more than perhaps any other to improve postpartum mental health. “I wanted to see her be screened, to get the treatment and the support she needed so that she can get well.”

I couldn’t agree more when it comes to women in real life — but I am reluctant to hold a movie to the same standard.

I think the fact that Marlo does not seek treatment is precisely the intention of Diablo Cody, the film’s screenwriter. Most people have never heard of postpartum psychosis, and some estimates suggest that more than 70 percent of moms with any maternal mental illness do not get diagnosed or treated, so any depiction of maternal mental illness that stokes controversy could be good for treatment. By creating a provocative film, Cody is generating discussion and awareness around this issue.

But Tully could have gone even further in this direction if it showed the lasting results of our society’s determination to ignore such symptoms. Maternal mental illness is real and scary and isn’t solely caused by clueless husbands and too little sleep. (Though neither of those helps, with lack of sleep especially considered a major risk factor for both postpartum depression and postpartum psychosis.)

At the end of the movie, we see the husband assisting with baby care and sharing Marlo’s earbuds while helping her cook dinner. The final shot of the two of them, intimately touching shoulders, implies a closeness and peace that puts a balm on her illness and implies all is well. An ending more consistent with what I take to be Cody’s intentions would have showed the husband’s increased efforts and engagement but Marlo, undiagnosed and untreated, still ill. That would have been a truly brave, and accurate, film about society’s treatment of mentally ill mothers.

Yet given how few depictions of postpartum mental illness exist, the benefits of Tully outweigh the negatives. May 2 was World Maternal Mental Health Day. I don’t think it’s any accident that Tully opened this week. Let’s take this film as a way to raise awareness and to keep talking about the importance of recognizing and treating maternal mental illness, for all the suffering mothers and for their children.

Correction: Diablo Cody is the screenwriter, not the director, of Tully.

Dr. Lauren M. Osborne is an assistant professor of psychiatry and behavioral sciences and of gynecology and obstetrics at the Johns Hopkins University School of Medicine. She is an expert on the diagnosis and treatment of mood and anxiety disorders during pregnancy, the postpartum, the premenstrual period, and perimenopause. She conducts research on the biological mechanisms of perinatal mental illness, with a focus on the immune system, and her work is supported by the Brain and Behavior Foundation and the NIMH.

First Person is Vox’s home for compelling, provocative narrative essays. Do you have a story to share? Read our submission guidelines, and pitch us at firstperson@vox.com.

Pregnant women can feel pressured to go off antidepressants. But that carries risks too.

2018-05-02T11:34:27-04:00

Last week, I saw a new patient — let’s call her Mandy — who came to consult me after her obstetrician and her psychiatrist both told her she’d need to stop taking her antidepressants for the duration of her pregnancy. Mandy had been taking the medication for severe obsessive-compulsive disorder and was unsure how she would manage once she went off the drugs.

This is a familiar scenario to me. I’m a psychiatrist who focuses on pregnant women at an academic medical center, so I am asked multiple times a day — by patients, colleagues, friends, reporters, even random people at cocktail parties — about whether it’s safe for pregnant women to take psychiatric medications.

Almost never am I asked, however, about whether psychiatric illness itself is harmful to mothers and babies, and what the risks might be of stopping medication while pregnant. My colleagues in internal medicine report little difficulty in reassuring their patients with other chronic medical illnesses such as diabetes, epilepsy, and asthma that the benefits of taking these medications generally outweigh the risks in pregnancy, even though the amount of published literature ensuring the safety of drugs for these conditions is far less than that for antidepressants. So why the discrepancy?

Don’t get me wrong. I’m not saying that all psychiatric drugs during pregnancy are without risk. In an ideal world, we would avoid exposing a growing fetus to anything that could disrupt the uterine environment and that child’s developing brain and body.

Every woman and every pregnancy is different, and it’s always up to the individual to make her own decisions about what’s right for her and for her baby — but every woman also has the right to informed advice from her health care providers, and many women aren’t getting it.

There are risks to stopping medication during pregnancy, and those risks aren’t talked about enough. It’s yet another example of the stigma surrounding use of antidepressants and our society’s underlying inability to treat mental illness as a real disease.

Research shows that the mother’s mental health can impact a birth

Because it’s generally considered unethical to randomize healthy pregnant women to take a drug during pregnancy, we have no gold-standard randomized trials on the safety of using psychiatric drugs during pregnancy. Adults can consent to a study that might cause them harm, but a fetus cannot — so most research governing boards are reluctant to approve such studies.

We do, however, have an enormous body of increasingly sophisticated scientific literature pointing to the relative safety of most of these drugs, and that literature is beginning to tackle the risks of these drugs in conjunction with the risks of the reasons women are taking them.

Last year, there were more than 100 scientific articles published on the safety of antidepressants alone, not including all the other psychiatric medications such as mood stabilizers and antipsychotics, which are used commonly in bipolar disorder.

Nearly anything a mother encounters is a potential risk for a fetus, from the fish we now warn mothers against to the polluted air they breathe to cigarettes and marijuana and antibiotics — all of which are used by more women in pregnancy than are psychiatric drugs. What the doomsayers rarely consider, however, is that exposing a fetus to a psychiatric illness is itself is a potential risk and can lead to serious consequences for both mother and child.

Earlier this month, the New York Times Magazine ran a cover story about the alarmingly high rates of infant mortality and maternal death during birth in the black population, both several times higher than in the white population. One likely cause, researchers say, is toxic stress and racial discrimination.

The scientific literature is full of articles about the effects of stress and of depression and anxiety on pregnant women and their fetuses. These effects include higher rates of preterm birth, low birthweight, preeclampsia, and miscarriage as well as effects on child emotional and cognitive development.

The mechanisms by which these illnesses exert their effects are both indirect and direct. Indirectly, depressed women are more likely to smoke and use substances, more likely to be obese, and less likely to adhere to good prenatal care such as a healthy diet and regular appointments with an obstetrician or midwife.

Direct effects of mental illness include increased production of stress hormones, changes in immune activity, and decreases in the placenta’s ability to protect the fetus from stress. Some of the most intriguing current research finds that these effects play out differently depending on the sex of the fetus.

The effects of mental illnesses are known and quantifiable and call out for treatment during pregnancy. Yet so many mothers-to-be and the professionals who advise them on their care assume that women can and should go without treatment for their mental illnesses.

Treatment doesn’t always mean medication. In fact, every treatment decision for a pregnant woman with mental illness should be individual. Each decision should take into account the history of a woman’s illness, its severity, and her response to various treatment regimens. It should also take into account her preferences, her support system, and the degree to which she is able to access other evidence-based treatments such as psychotherapy, prenatal yoga, and artificial light therapy — all of which require specialized providers and are often not covered by insurance.

But for many women, these options are either inaccessible or not powerful enough. Why do we make those women feel that their suffering is not worth taking seriously? Doctors are very comfortable giving pregnant women medications for diabetes, seizures, and asthma, not because our evidence about the risks of those drugs is any better (in fact, the anti-seizure drugs are the very same drugs that women with bipolar disorder are often asked to stop for pregnancy) but because the medical community, and society at large, agrees that diabetic comas, seizures, and lack of oxygen are bad for babies. Neither doctors nor society at large seems to understand, or perhaps to care, that mental illness is also bad for babies.

Stigma around mental illness is a powerful force.

I frequently ask the medical students I teach to define the leading causes of maternal death in the first year after birth. They will accurately identify hemorrhage, preeclampsia, and blood or fluid clots as major killers. No one guesses suicide, and yet in many places, suicide is the leading cause.

While the US does not categorize postpartum suicides as pregnancy-related deaths, individual states have released studies showing suicide to be the leading cause of post-pregnancy death. And other countries, such as the UK, have placed suicide as the No. 1 cause of pregnancy-related death. A dead mother certainly isn’t good for a baby.

Suicide after pregnancy is usually linked to postpartum depression. Depression and anxiety during pregnancy are leading risk factors for postpartum depression, and most women who stop psychiatric medications for pregnancy will experience a relapse in their mental illness at some point during pregnancy or afterward.

One in three of those who relapse will become suicidal. But even when women are not suicidal after giving birth, depression isn’t good for babies. We have overwhelming evidence of the deleterious effects of postpartum depression on children’s cognition, development, and emotional functioning. So why, given what we know about the link between pre-birth depression and postpartum depression, isn’t treating mental illness in pregnancy not only accepted but a priority?

The answer is simple: It’s stigma about mental illness. We’ve made some progress — Brooke Shields, Gwyneth Paltrow, and other celebrity moms have shared their experience with postpartum depression with their fans — but for the most part, we still think of depression as a moral weakness rather than a medical illness. We’ll let moms pop Tylenol (whose risks we are just beginning to understand) liberally for headaches, but we expect them to “just live with” depression.

This is such a shortsighted view, both for the next generation and for the mothers themselves. Their suffering is often downplayed when we devote all our attention to the effects of medications on babies. Can’t we do better?

First Person is Vox’s home for compelling, provocative narrative essays. Do you have a story to share? Read our submission guidelines, and pitch us at firstperson@vox.com.