Recognizing Postpartum Mood Disorders and Psychiatric Disorders

We’ve all seen the commercials for diapers and other baby products that depict postpartum life for moms and newborns as a picturesque routine of  snuggles and cozy days at home recovering and bonding. 

However, in reality, the first few weeks, months, and even years after giving birth can be a struggle—marked by mental health concerns, including postpartum mood disorders and psychiatric disorders. 

Although social media and medical providers are helping to spread the word about these disorders, there is still a tremendous lack of awareness about the signs, symptoms, and available treatments.

According to the American Psychological Association (APA), one in seven women experience postpartum depression, one of the most commonly known disorders associated with childbirth. 

While depression is among the most commonly diagnosed postpartum disorders, practitioners will want to be prepared to identify other postpartum mental health issues which may also occur among clients, family members, and friends and acquaintances. 

Equipping yourself with the tools and knowledge to support postpartum mental health care is essential. 

Increased rates since the pandemic

A July 2022 study, published in the Journal of Psychiatric Research, reported that national rates of self-reported postpartum depressive symptoms have “significantly” increased following the start of the COVID-19 pandemic. 

Other studies, such as a March 2022 study from the University of Michigan, show much more alarming numbers—stating one in three new mothers screened positive for postpartum depression in the early COVID-19 days, which is triple pre-pandemic levels, and one in five had major depressive symptoms. 

Researchers pointed to stressors such as limited breastfeeding support during the pandemic and worrying about contracting COVID-19 itself.

It’s not all depression—patients and providers determine the different postpartum mood disorders

While postpartum depression is more widely understood and discussed publicly, other mood disorders and psychiatric conditions are equally prevalent and difficult to navigate. 

Kayla Acklin, PhD, Assistant Professor of Counseling at Mississippi College, has researched and worked extensively with perinatal mental health clients. According to Acklin, postpartum mental health conditions can vary symptomatically and in severity. 

“The disorders are lumped into a term called perinatal mood and anxiety disorders,” she says. “That encompasses depression, anxiety, OCD, and psychosis, so from pretty mild to rather severe and emergent [conditions]—it’s a big spectrum.” 

Accurate diagnosis is essential for accessing helpful treatment. 

Here’s how to tell the difference.

A case of ‘baby blues’

After giving birth and for a few subsequent weeks, some new mothers may find themselves weepy, moody, more emotional than usual, and wondering if they have postpartum depression. 

The American Pregnancy Association reports that 70% to 80% of all new mothers experience some of these negative feelings, which are normal and thought to be caused by hormone changes. Although they can “hit forcefully” within four to five days after the birth, they don’t necessarily warrant a postpartum mood disorder diagnosis.

According to Acklin, they might just be experiencing a normal hormone fluctuation reaction—colloquially called the “baby blues,” which is not considered a postpartum mood disorder, but is often confused with these more serious mental health issues.

“With ‘baby blues,’ by four weeks post-birth they should be resolving,” she says. “However if it’s true postpartum depression, symptoms will linger past four weeks.” 

Postpartum depression

Clinicians familiar with major depressive disorder will recognize that postpartum depression (PPD) looks very similar. 

According to Gauri Khurana, MD, psychiatrist and Instructor at Yale University’s Department of Psychiatry, common signs of postpartum depression include changes in sleep from one’s baseline, changes in appetite, depressed/sad mood, anhedonia (loss of interest in activities that one used to find pleasurable), poor concentration, tiredness, feelings of guilt, and suicidal thoughts. 

Khurana says that the onset of postpartum depression can occur anytime within the first year after giving birth. Additionally, a type of “delayed” PPD can occur between 12 and 16 months after the birth. 

Treatments for PPD include a combination of antidepressant medications, such as sertraline

(Zoloft), and therapy, such as cognitive behavioral therapy—aiming to improve the client’s functioning and quality of life. 

Acklin says that parents might also struggle to bond with their babies and they might not have motivation to “get up and do things,” and that these may compound into “mommy guilt,” which can further complicate postpartum mental health issues. 

Postpartum anxiety

Though it’s sometimes lumped in with PPD, postpartum anxiety (PPA) is an entirely separate condition experienced by 11% to 21% of birthing parents. The key difference is that moms with PPA might be more worried, as opposed to sad. 

“A lot of the thoughts and feelings center around your baby,” Acklin says. “I’ve had moms tell me things like, ‘What if I’m carrying a baby down the stairs and I fall and they die?’” She adds that the thoughts tend to be pretty scary and spiral into worst-case scenarios pretty quickly. “With PPA, moms tend to really cling to their babies,” and might have “nervous energy.”

Treatments include medication, such as selective serotonin re-uptake inhibitors (SSRIs), and therapy. 

Acklin adds that providers must have specialized knowledge of how and when to provide anxiety and depression medications throughout pregnancy and breastfeeding—mitigating the risks of maintaining prior mental health medications versus changing or stopping them. 

Additional symptoms of PPA from the Cleveland Clinic include:

• Disrupted sleep
• Increased heart rate or palpitations
• Shortness of breath
• Loss of appetite
• Tense muscles
• Trouble sitting still or feeling calm
• Racing through or obsessions about terrible scenarios
• Forgetfulness, difficulty concentrating, or irritability
• Avoiding certain activities or places
• Trying to control your environment

While psychiatrists and psychiatric nurse practitioners (PMHNPs) can treat both PPD and PPA, Khurana says OBGYNS do it more often due to “issues with access,” as psychiatric services can have wait times of upwards of three months.

“For cases of PPD that do not improve with a trial of one or two medications in the span of one to two months, these women should be referred to psychiatrists,” she says.

Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder (OCD) in the postpartum period happens when significant anxiety symptoms manifest as OCD and other ruminative conditions. 

According to Khurana, “Women in the postpartum period may also experience clinically significant anxiety symptoms such as generalized anxiety, panic attacks, and hypochondriasis. There are case reports of postpartum obsessive-compulsive disorder in which mothers report intrusive thoughts of hurting their child.”

Jade Kearney is a New York mother of two, and CEO of SheMatters, an organization working towards cultural competency in the maternal mental healthcare space. She says that fears of sudden infant death syndrome (SIDS) in her baby’s early weeks meant she couldn’t stop watching her baby. 

“It was turning me into an obsessive person—I already had hypochondria throughout my younger years…it showed its ugly face when I had my daughter,” she says. 

Kearney recalls having intrusive thoughts, such as, “What if I throw her out the window?—I lived in an apartment in the city…[so I worried about] anything that was dangerous. What if I harm her? What if I let the stroller go? I felt like the worst mom in the world,” she says. But her intrusive thoughts are just one of many symptoms of postpartum OCD. 

Other postpartum OCD symptoms include:

• Avoiding reaching out to others about thoughts of harming yourself or your baby
• Fear that you might harm the baby when you don’t really want to
• Compulsions meant to control or stop bad things from happening to the baby, such as frequently checking on them or over-bathing them
• Avoiding certain activities like walking up and down stairs
• Trouble sleeping

Kearney reached out to her OBGYN, who prescribed Zoloft, but she wasn’t comfortable with the prescription. “It’s a cultural stigma in the Black community—we don’t really take antidepressants. At SheMatters, we have so many moms that flush that medication down the toilet,” Kearney says, calling it a “ridiculous” misconception around medication for mental illness, stemming from distrust in the medical system. 

“It was getting really bad. Everything was obsessive. I couldn’t sleep, I didn’t want to eat, I was pumping but my milk wasn’t coming in…I just had an intense amount of stress, and it was coming out as OCD.” Kearney also remembers repeating her daughter’s name, worrying she would forget her.

In her quest to address her postpartum OCD, Kearney struggled to find a culturally competent therapist, but eventually enlisted the help of a psychiatrist who diagnosed her with OCD. 

Now, after making a recovery, she is working with other moms at SheMatters to improve cultural competency in maternal mental health practices, including rewriting the Edinburgh scale—a diagnostic tool used to diagnose PPD—to be more culturally inclusive of all birth-givers. 

Kearney says some questions missed the mark. For example, one asks, “Do you feel like things are getting on top of you?” She didn’t know what that meant and knows it doesn’t translate well in Spanish. 

Kearney also created the Pink Book, a map outlining safe delivery options based on mortality rates, C-section rates, and patient surveys, hoping to change the journey for others.

Postpartum psychosis

Holly Puritz, MD, OBGYN and Board Advisor at Lucina, a maternity care analytics tool and platform, vividly remembers a patient with postpartum psychosis (PPP). 

Her “very distraught” husband had rushed his wife, a high-level executive in healthcare, to the emergency room after she said she heard the baby talking, telling her that she was the wrong mother for the baby, and that she felt that she needed to “not dispose of, but in some way separate herself from the baby.” 

Khurana says PPP is an emergency situation in many cases, as it involves “rapidly evolving manic” episodes, sometimes including these types of delusional beliefs often focused around the health of the infant, and auditory hallucinations that can lead to hurting the baby or herself. It happens to 1 in 1000 postpartum women and typically occurs in the first three months after giving birth, sometimes to those who have previously been diagnosed with bipolar disorder. 

“This is a severe break from reality, hence the term psychosis,” Khurana says. “I worry about suicide and infanticide in mothers with PPD and PPP.”

Puritz says her patient with PPP was admitted to a psychiatric hospital where she stayed for a week, improving with the help of “very significant medications.” After discharge, she received ongoing care and medication management continued over the course of a month. . “She is now the happy mother of a two-year-old, and psychosis is in the past.” 

Not all mothers have that positive outcome, as 5% of those diagnosed die by suicide, and there is a 4% infanticide rate. Acklin says some moms hesitate to get help out of fear they’ll be separated from their babies, but help is essential to ensure the health of parents and babies. 

Those in a PPP-related emergency should promptly call 911, experts advise. If they pose a danger to themselves, they can always call or text the National Suicide Prevention Hotline.

Preventative tips for postpartum mood disorders

While each of these disorders can feel scary, lonely, and even terrifying, clients with these symptoms can start seeking support by reaching out to a friend, family member, doctor, or therapist, Acklin says. 

If you’re a clinician caring for a client with postpartum mental health issues, make sure you’re well-educated on the nuances of postpartum care, or refer them to a specialist. 

It’s important that clients are treated by a mental health professional or OBGYN to address their postpartum mental health concerns.

Lastly, clinicians and postpartum support systems can encourage patients to prioritize themselves daily in any of the following ways: 

• Spending time in sunlight, such as going for a short walk
• Getting in some movement once exercise restrictions have been lifted
• Taking a shower or nap
• Grabbing a coffee with a friend
• Scheduling time for yourself to do something you enjoy
• Prioritizing self-care tasks like doctors appointments 

Most mothers enduring postpartum mood disorders can, and will, make a full recovery.

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