“It’s okay to tell me that you’re not okay.”
Postpartum depression (PPD) and postpartum or perinatal mood and anxiety disorders (PMADs) are the most common medical concerns for women after childbirth. Yet few medical and mental health professionals really know how prevalent and serious PPD and PMADs are.
There is a great need for better screening to identify women struggling with postpartum disorders. Likewise, more therapists and mental health providers need to know about treatment approaches that are effective in stabilizing and managing symptoms. Those who work with pregnant women and new mothers, as well as children, are in a good position to help.
A Surprising Number of Women Screen Positive for PPD
In the largest study to date, Northwestern Medicine researchers found that one in seven new mothers (14% of the 10,000 interviewed by telephone) screened positive for depression between 4 and 6 weeks after giving birth. Among those who received follow-up for the first year after giving birth, 22% had experienced depression.
The most common follow-up diagnosis among the 14% who screened positive was major depressive disorder. Almost two-thirds of these women were found to have additional conditions including anxiety and bipolar disorders.
Occurrence of Other PMADs Also Needs Greater Awareness
Women who experience obsessive thoughts and anxiety are often very confused by their symptoms, because they come unexpectedly, and are widely misunderstood. The obsessive-compulsive thoughts and crippling anxiety of these disorders receive even less attention than PPD. Some brief information on these disorders:
- Postpartum Obsessive Compulsive Disorder (PPOCD) is diagnosed for 3-5% of postpartum women. Brain imaging studies show that the active area is the part that controls maternal instinct, or protective behavior. PPOCD appears to come from intrusive protective (maternal) thoughts.
- Celebrity Brooke Shields struggled with a postpartum mood disorder and is helping raise awareness in her book Down Came the Rain.
- 50% of women with bipolar disorder are first diagnosed during postpartum care.
- 60% of bipolar women present initially as depressed during postpartum care.
- 85% of bipolar women who stop taking medication during pregnancy will experience a relapse of symptoms before the end of pregnancy, according to this study.
Mothers Reluctant to Report Symptoms
Despite these findings, postpartum mental health conditions still go unrecognized and untreated for many women. This is partly because many new mothers feel too ashamed to admit to the difficulties they are having. Also, professionals may not be fully aware of the latest information about the nature of perinatal mood disorders, their prevalence, and how to screen pregnant and postpartum mothers more effectively.
Among the 14% of women in the Northwestern Medicine study who screened positive for PPD, some raised very serious concerns. “We discovered 20% had suicidal thoughts − these are thoughts of death, thoughts of wanting to die, not wanting to wake up,” said one study investigator, Dorothy Sit. It is likely that some women’s lives were saved because of follow-up care offered to study participants. However, “some patients with very severe symptoms had made the decision to take their lives,” Sit reported.
Like study author Katherine Wisner, MD, I agree that undiagnosed PPD is a huge public health concern. As medical and mental health clinicians, we can do more to address these issues. Greater awareness among doctors, nurses, obstetricians, pediatricians and mental health professionals is critical to meeting this underserved need.
Why Women Hide Their Symptoms
Just about every woman with a new baby will say it’s a wonderful time. But it’s important to realize that not every woman will truly feel this is the happiest event in her life. She may very much want to experience the love and joy that she expected. But many women are confused and alarmed to discover they do not − and cannot − feel the elation and other emotions others believe are “normal” for new mothers.
Doctors (and therapists, too) need to know that a woman at risk for postpartum depression, anxiety or other mood disorder may look and behave like any other new mom. Mother and baby come to their appointment on time. Mom is dressed and has her makeup on. The obstetrician or pediatrician sees that she looks good. It may seem as if there is no need to check for depression.
But there is a real need for doctors to ask more questions and to take time to look below the surface.
The Need to Ask the Right Questions
Well-intentioned pediatricians and obstetricians may simply ask, “How are you doing?” Between chatting, admiring the baby, and reviewing patient records on the computer, the mom’s emotional state may only get a passing glance.
Truly screening for PPD means knowing that many mothers who are struggling also desperately want to look and play the part of a “normal mom.” They are afraid to broadcast that they do not feel all right
Asking the right questions means going beyond “how are you?”
Greater knowledge of symptoms and assessment tools can make a big difference in our ability to recognize postpartum mental health issues as clinicians. Some common screening tools include:
- The Edinburgh Postnatal Depression Scale (EPDS), published in 1987. This is the most common screening tool for PPD in the general population. It is freely available in print and online and provides a number score that can help signal the degree of risk for depression.
- The Mood Disorder Questionnaire (MDQ) was developed around 2002 to help screen for bipolar spectrum disorder. It contains 15 questions and can be used to help evaluate the pattern of symptoms and the need for further assessment.
- The Postpartum Distress Measure (PDM) came about in a 2011 study to help find a tool to assess postpartum distress, including depression and anxiety.
The Postpartum Stress Center (PPSC) provides free downloadable copies of these tools, plus additional assessment tools to help clinicians recognize and talk about issues with women who are struggling with symptoms. Some of these tools include:
- The PPSC Suicide Assessment – These follow-up questions are intended for clinicians who administer the Edinburgh Postnatal Depression Scale and wish to do additional screening.
- Postpartum Psychosis Emergency Room Screening Guidelines – This fact sheet is for healthcare workers and first responders to help them recognize psychotic symptoms and the urgency of the situation so they can get appropriate support promptly.
See Assessment Tools for Your Practice at the PPSC for complete details and links.
Postpartum depression is one of several mood disorders that new or expectant mothers may experience. There are a range of disorders that screening can help identify, including:
- Postpartum Stress Syndrome (Kleinman & Raskin, 1996) — A term coined by Karen Kleinman, LCSW, and Dr. Valerie Raskin, to describe the difficulty some mothers experience with daily, persistent distress. These symptoms do not meet the DSM criteria for a major depressive episode or anxiety disorder, but present as an adjustment disorder that does not readily resolve on its own.
- Postpartum Depression Disorder (PPD) — The onset of depression symptoms usually within three months and up to 1 year after childbirth.
- Postpartum Anxiety or Perinatal Anxiety — Anxiety that occurs after or during pregnancy, which can take many forms, such as intense nausea, disturbed sleep patterns and acute, persistent worry. While diagnostic criteria are not yet established, it is beginning to receive more recognition and study.
- Perinatal Obsessive-Compulsive or Postpartum Obsessive-Compulsive Disorder (PPOCD) is the most misunderstood and misdiagnosed condition, says Postpartum Support International. About 3-5% of new mothers experience intrusive, scary thoughts that may lead to hypervigilance and a persistent sense of horror, and may occur whether or not a person has been diagnosed with OCD before.
- Postpartum Psychosis — A rare illness, usually with sudden onset within the first two weeks after childbirth. Symptoms can include delusions, paranoia, insomnia and paranoid suspicions. The presence of symptoms is a medical emergency and it is critical to act promptly and get immediate help. Call a doctor or emergency crisis line such as the National Suicide Prevention Hotline at 1-800-273-8255.
- Postpartum Bipolar Mood Disorder — Many women who are diagnosed with bipolar disorder receive support for the first time during pregnancy or postpartum. A person experiences intense moods that cycle in phases (lows and highs), or which may both occur together. It is very important to find a professional informed in assessing and treating bipolar symptoms during pregnancy and after childbirth.
When a Postpartum Mother Needs Treatment: What to Do
Having a good referral network of qualified therapists can help more mothers get access to mental health care. Many prenatal care providers maintain a list of therapists, psychologists and other providers to call on for mental health referrals.
Some therapists (myself included) have a special interest in treating postpartum depression and mood disorders and supporting better mental health for mothers and parents. We have taken postgraduate training to understand the needs of new mothers who are struggling. The Postpartum Stress Center maintains a nationwide directory list of therapists who have successfully completed postgraduate training at the PPSC. Postpartum Support International (PSI) and its local affiliates also have a directory of therapists and psychiatrists nationwide. PSI has a great local directory to support services. These resources are just some ways the medical community can find therapists who are prepared to treat perinatal mood disorders.
Finding a Therapist for Postpartum Treatment
It may not be possible to get access to a provider who specializes in postpartum disorders in your area. However, it is important to know that PPD is treatable. You may be able to find a good therapist who is skilled in treating women and depression.
I find that a trauma-informed approach is a particular strength in addressing mental health issues for everyone, including new mothers. This approach helps therapists create a safe space where it is absolutely “okay to tell another person that you’re not okay.”
As medical and mental health clinicians, greater awareness of PPD, perinatal mood disorders, and treatment options can save more lives and help more families access the care they need. We can be our most proactive and effective by learning more and talking more about PPD assessment and treatment.
- Support and Resources in the United States
- Overview of Pregnancy and Postpartum Mental Health Disorders
Anxiety in Childbearing Women: Diagnosis and Treatment, by Amy Wenzel
Beyond the Blues, Understanding and Treating Prenatal and Postpartum Depression & Anxiety by Shoshana Bennett and Pec Indman
Dropping the Baby and Other Scary Thoughts: Breaking the Cycle of Unwanted Thoughts in Motherhood, by Karen Kleiman, MSW and Amy Wenzel, PhD
When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women, by Penny Simkin and Phyllis Klaus
Facing Postpartum Depression: The Honesty, Courage and Support It Takes to Seek Help for PPD by Robyn Brickel, MA, LMFT
How do I find a PPD Therapist? by Karen Kleinman, LCSW
Northwestern study finds new moms at far more risk for OCD by Patrick Svitek, Chicago Tribune reporter
The Mood Disorder Questionnaire: A Simple Patient-Rated Screening Instrument for Bipolar Disorder by Robert M.A. Hirschfield, M.D.
Onset Timing, Thoughts of Self-harm, and Diagnoses in Postpartum Women with Screen-Positive Depression Findings by Katherine L. Wisner, MD et al.
Risk of Recurrence in Women with Bipolar Disorders in Pregnancy, Am. J. Psychiatry 2007, by Viguera. A, et al.