By Danielle J. Johnson, MD, FAPA
Lindner Center of HOPE, Chief of Adult Psychiatry
May is Maternal Mental Health Awareness Month. One in five women will develop a maternal mental health disorder. They are also referred to as perinatal mood and anxiety disorders (PMADs) to emphasize that women experience more than postpartum depression during pregnancy and after birth. Women who have symptoms of PMADs might not seek help because of guilt, shame, or embarrassment for feeling something different than the expected norms of motherhood. Awareness and education are important to reduce stigma so mothers and babies get the help they need.
PMADs can occur during pregnancy or up to one year after giving birth. The most common PMAD is the “baby blues”, affecting up to 80% of new mothers. Symptoms include sudden mood swings, loneliness, sadness, crying spells, loss of appetite, problems sleeping, irritability, restlessness, and anxiety. These symptoms are a normal adjustment to changes in hormones and resolve without treatment in two to three weeks.
About 10% of women experience depression during pregnancy and about 15% during the first year postpartum. Feeling sad, hopeless, helpless, or worthless; fatigue, difficulty sleeping or sleeping too much, appetite changes, difficulty concentrating, crying, loss of interest or pleasure; lack of interest in, difficulty bonding with, or excessive anxiety about the baby; feelings of being a bad mother, and fear of harming the baby or self are symptoms of peripartum depression. Risk factors include poverty, being a teen mother, advanced maternal age; personal or family history of depression, anxiety, or postpartum depression; premenstrual dysphoric disorder, inadequate support, financial stress, relationship stress; complications in pregnancy, birth or breastfeeding; a history of abuse or trauma, a major recent life event, birth of multiples, babies in neonatal intensive care, infertility treatments, thyroid imbalance, and diabetes.
Anxiety can occur alone, or with depression, in 10% of new mothers. Symptoms include constant worry, racing thoughts, inability to sit still, changes in sleep or appetite, feeling that something bad is going to happen; and physical symptoms like dizziness, hot flashes, and nausea. Some mothers may also have panic attacks with shortness of breath, chest pain, dizziness, a feeling of losing control, and numbness and tingling. Risk factors are a personal or family history of anxiety, previous perinatal depression or anxiety, and thyroid imbalance.
Post-traumatic stress disorder (PTSD) can occur in up to 6% of mothers following a traumatic childbirth. Possible traumas are prolapsed cord, unplanned C-section, use of vacuum extractor or forceps to deliver the baby, baby going to NICU; and feelings of powerlessness, poor communication and/or lack of support and reassurance during the delivery. Women who have experienced a previous sexual trauma are also at a higher risk for developing postpartum PTSD. Intrusive re-experiencing of the traumatic event, flashbacks or nightmares; avoidance of stimuli associated with the event; increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response); anxiety and panic attacks, and feeling a sense of unreality and detachment are symptoms of PTSD.
Obsessive-compulsive disorder (OCD) can occur in 3% to 5% of new mothers. Obsessions are persistent, repetitive thoughts or mental images, often related to the baby. Obsessions can be so bizarre or disturbing that they can be mistaken as psychosis. Compulsions are repetitive acts performed to reduce obsessions. Mothers are distressed by the obsessions which can lead to a fear of being left alone with the baby or hypervigilance in protecting the baby. Mothers with postpartum OCD know that their thoughts are out of the ordinary and are unlikely to ever act on them.
Postpartum psychosis is the most severe of the PMADs. It is often associated with an episode of bipolar disorder. It is rare, occurring in 1 to 2 per 1000 women. The onset is abrupt, within 48 to 72 hours and up to two weeks after delivery. This is a psychiatric emergency, requiring immediate treatment. Mothers may experience hallucinations (hearing voices or seeing things) and/or delusions (believing things that aren’t true.) If psychosis occurs as part of a bipolar manic episode, there might be additional symptoms such as irritability, hyperactivity, decreased need for or inability to sleep, paranoia and suspiciousness, rapid mood swings, difficulty communicating, and confusion or memory loss. Risk factors are a personal or family history of bipolar disorder or a psychotic disorder. Most women with postpartum psychosis do not have violent delusions but there is an up to 5% rate of infanticide or suicide due to acting on delusions or having irrational judgement.
PMADs are the most common complication of pregnancy and childbirth. They are treatable with psychotherapy and/or medication and early intervention provides relief for the mother and ensures the baby’s wellbeing.