Postpartum Mental Health:Beyond the Baby Blues

Dr. Alison Stuebe, an OB/GYN at the University of North Carolina captured a core injustice in maternal healthcare in saying: “The baby is the candy; the mom is the wrapper, and once the candy is out of the wrapper, the wrapper is cast aside.” Her interview with NPR was much of the inspiration behind my interest in the topic of postpartum mental health. Give it a name: “postpartum”, “baby blues”, or “maternity madness”, there are plenty of ways we talk about maternal mental health without truly unpacking it¹. In some ways, this is related to the stigma around mothers seeking out help. There is a degree of shame around being deemed a bad or incapable mother for not being able to provide for a newborn at the highest level. Those who suffer from postpartum mental health issues then face a unique double burden of their own symptoms layered with experiences of external shame. That being said, the epidemiology of any mental health condition is complex and varies greatly between populations. What may be a central driver of postpartum psychosis in one community may not be relevant to the next, though there may be shared themes. To quantify the urgency of postpartum mental health needs, nearly 23% of pregnancy-related deaths in the United States can be attributed to a mental health condition, whether it be suicide, overdose, or poisoning². For comparison, this accounts for a larger proportion of maternal deaths in the United States than even hemorrhage. It has been well-documented over time that most maternal deaths are preventable, which places mental healthcare professionals in a critical position for addressing the maternal mortality crisis. In this blog, the goal is to demystify the psychological changes that occur during and after pregnancy by clarifying key terminology, disorders, and resources for making maternal transitions easier and safer for all.

In terms of diagnostics, it was not until 1994 that the Diagnostic and Statistical Manual of Mental Disorders (DSM) made an explicit nod to postpartum mental health conditions by adding a specifier under the diagnoses of major depressive disorder, bipolar I, and bipolar II that applies for symptoms beginning in the postpartum period. This has now been updated to include symptoms in the peripartum period, referring to the duration of pregnancy and the four weeks that follow. Unfortunately, researchers have expressed concern that many symptoms of postpartum mental health issues may surface longer than a month out from someone’s delivery date, depending on personal factors and environmental conditions³. Additionally, it can be difficult to differentiate whether an individual’s symptoms are a function of a prior history of undiagnosed mental illness that worsened during pregnancy, or the precipitant for the symptoms is the peripartum period itself. Another concern in diagnostics relates to anxiety disorders, which do not use peripartum onset as a specifier. If someone’s symptoms did not meet the six month timeline in DSM criteria for generalized anxiety disorder, despite specific onset in the peripartum period, they may be appropriately diagnosed. Often, practitioners and researchers will approach peripartum anxiety with 1 month of symptoms during or after pregnancy as the subcriteria, though this is not specified in the DSM⁴.

 

Understanding the major postpartum mood disorders:

While this is in no way a comprehensive review of literature on the unique and varied forms of postpartum mental health concerns, this overview provides a foundation to understand key differences and hallmarks of each condition, though they vary between individuals. Once again, the terms used here are not represented as unique diagnostic codes within the DSM, but colloquially are referred to as distinct disorders, given how research and clinical practice has mirrored this. This short table reviews key details of each presentation⁵:

	Symptoms	Risk Factors
Post-partum depression6 Prevalence: 10-20% of mothers postpartum	Persistent sadness, apathy, hopelessness, irritability, or disinterest in regular activities Changes to concentration, sleep, eating, and typical self-care habits Social withdrawal, strong feelings of guilt or shame, potentially related to parenting Suicidal thoughts or thoughts of self-harm	Prior history of depression, low social support, or exposure to stressful life events, high-risk pregnancy, infant with health complications
Post-partum anxiety4 Prevalence: 10-15% of mothers postpartum	Persistent and excessive fear, worry, or restlessness, potentially regarding infant health and development, partner/maternal capability, health changes, or mortality Insomnia, concentration issues, fatigue Apprehension about specific environments, people, or potentially stressful stimuli	Co-occurs frequently with post-partum depression, so risk factors overlap Personal, partner, or family history of mood, anxiety, or eating disorders
Post-partum psychosis7 Prevalence: 1-2 in every 1,000 mothers	Confusion, disorganized behavior or thinking, withdrawal Mood-incongruent delusions that are paranoid, grandiose, or bizarre, often about harm to infant or self, persecution from infant or familiy, jealousy, or infant identity Visual, tactile, or olfactory hallucinations Mood swings, sleep disturbances	History of bipolar disorder or schizoaffective disorder Prior psychotic symptoms Poor sleep hygiene Environmental stressors (e.g. marital discord) Rapid onset behavioral/cognitive changes, often within 2-4 weeks post delivery
Post-partum obsessive compulsive disorder (OCD)8 Prevalence: 3-5% of mothers postpartum	Obsessions: Fear of harm to the unborn/infant, or a mother’s fear of unintentionally harming the infant Unwanted or distressing thoughts that are sexual or violent, infrequently put into action relative to postpartum psychosis Avoiding activities with the infant due to this fear Compulsions: Behaviors that seek to control or stop obsessive thoughts might include- Frequently checking on the baby, excess sanitizing, repeating prayers or affirmations Sleep disruptions	Overlap with above conditions Personal/partner/family OCD or OCPD history Low social support or poor relationships High stress due to maternal transitions

As shown here, there are a variety of different risk factors that may increase the likelihood of developing a postpartum mental health condition, but there are not black and white lines between the drivers of each condition. While some hallmark symptoms help to differentiate between these experiences, prevention and treatment efforts should take care in prioritizing the variation within individual cases.

 

What is the Concept of Birth Trauma?

Not all experiences of postpartum mental health challenges will fit neatly into the categories above, birth trauma being one of these unique experiences that may add to the difficulties new mothers face. Birth trauma can be described as the physical or psychological harm that occurs as a result of experiences during childbirth⁹. While it may not seem like a mother delivering a baby could be classified as a traumatic event, many women feel neglected, dehumanized, or unheard in birthing settings. This is not a rare experience, and the effects of a mother’s shock or numbness as a result of their delivery impacts everyone involved, from the partner to the infant. Certain circumstances during the delivery process may be implicated in birth trauma, such as ignored pain relief needs, lack of decision-making power during procedures, unexpected medical interventions and invasive contact⁹. Many women also feel a sense of being out-of-body or out of control of what is happening to their body as multiple providers work around them at once. Serious pregnancy complications such as stillbirths, miscarriages, or emergency C-sections can be physical drivers of birth trauma, but other people might discuss emotional injury that made labor and delivery traumatic or distressing. This could be related to dismissive, unattentive, or even overbearing providers or partners who do not provide comfort to address a mother’s fears about her own or her infant’s death. Those who have experienced prior sexual assault or abuse are at higher risk for birth trauma related to the loss of control over one’s body¹⁰. Pre-existing mental health concerns, prior physical birth injuries, or a history of high-risk pregnancy can also be risk factors in this. A key way of preventing birth trauma is by sharing decision-making power and maintaining open communication with providers to ensure informed consent with every action that is taken¹¹. Another way of approaching this risk is by creating a thorough birth plan to guide decision making during labor and delivery by making preferences and boundaries known ahead of time. Discussing with doctors, maternal and child health nurses, midwives, or mental health providers can all be supportive measures to set expectations and debrief after a distressing birth experience.

 

What Can Be Done to Protect Mothers?

Because of increased concern with the risk of side effects in using pharmacological therapies during and after pregnancy, many researchers emphasize the use of psychodynamic, cognitive-behavioral, and interpersonal therapy efforts throughout the perinatal period¹². While this may not completely eliminate symptoms, these strategies, started early on, can equip mothers with the tools they need to better tackle mental health challenges if they emerge. Some women also benefit from support groups, nondirective, unstructured psychosocial counseling, or telephone-based crisis or peer support¹². Support groups for new mothers can address the social needs that can be a significant risk factor in postpartum depression, since a strong network can make all the difference during overwhelming or isolating experiences. Organizations like Post Partum Support International can be accessible resources in seeking help¹³. Because postpartum mental health is a core part of family health, involving partners in therapy can be a key part of making progress. As far as medications for postpartum depression go, sertraline, paroxetine and nortriptyline have been found to have the least passage into breast milk, which could be ideal for breastfeeding mothers factoring in their infant’s exposure¹². A recent pharmaceutical development, Brexanolone is specifically designed to treat postpartum depression to increase GABA receptor activity by mimicking the action of allopregnanolone¹⁴. There is some concern with this medication given conflicting data on its effects after 30 days of use as well as concerns over sedative side effects and cost barriers. Mood stabilizer, antipsychotic, and anxiolytic options for postpartum anxiety, psychosis, and OCD are more complex and require greater consideration of side effects, so monotherapy with lower starting doses and slow titration is preferred¹⁵. Ultimately, it is important for healthcare providers, from OB/GYNs to psychiatrists to therapists, to collaborate in creating a treatment plan that supports mothers comprehensively and honors their agency. Ideally, progress in the field of maternal mental health will ensure no mother is treated as a mere “wrapper”, devalued in comparison to their newborn. For individuals seeking out more information on maternal mental healthcare, UTHealth Houston McGovern School of Medicine has a collection of useful links found here.