What are Perinatal Mood and Anxiety Disorders?
These are groups of symptoms that can affect women during pregnancy and the postpartum period, causing emotional and physical problems that make it hard to enjoy life and function well. Mood disorders, such as depression or bipolar disorder, can include symptoms of sadness, loss of pleasure, or excessive happiness and energy. Anxiety disorders often include symptoms such as worrying too much, anxiety or panic attacks, and irritability. See below for more specific descriptions of normal mood variations with childbirth, as well as different types of mood and anxiety symptoms and disorders that can affect pregnant and postpartum women.
Normal Postpartum Adjustment
Becoming a new parent is stressful, and some difficulty adjusting to parenthood is considered normal. Normal postpartum adjustment may involve symptoms similar to Baby Blues (see below), and it is likely that most new mothers experience some of these symptoms during the first few months after childbirth. However, if these symptoms are interfering with mom’s normal coping abilities, functioning and parenting, something more serious (like a Perinatal Mood or Anxiety Disorder) may be happening.
This is a mild, short period of mood and physical changes experienced by approximately 60 – 80% of all women within the two weeks after delivery. Due to a sudden drop in hormones, a woman may feel sad, weepy, exhausted, anxious, tense and/or irritable. Women may cry for no reason or have mild trouble sleeping. However, if symptoms continue beyond the second week after childbirth, or include any thoughts about suicide, it’s not the “blues.”
What is Postpartum Depression?
Depression can occur during pregnancy or after childbirth, when it is commonly called “Postpartum Depression.” Depression that occurs during pregnancy can continue after the baby is born. Women with depression in the postpartum period can have symptoms start in the first few weeks after childbirth, or several months later.
Women with depression often report feeling like they can’t enjoy life as much as they used to. Some women feel sad and cry in response to big and little things, but other women describe themselves as excessively irritable and overwhelmed. (“I snap at every little thing my husband does.” “It just feels so hard to make it through the day.”) They can feel “snappy” and “on edge,” more negative than usual and guilty about things that wouldn’t have affected them in the past. Difficulty falling or staying asleep is common in depression. While pregnancy can cause insomnia because of feeling physically uncomfortable, and newborns wake up frequently, women with depression often describe not being able to sleep because they can’t stop thinking or worrying at night, which keeps them awake. (“It’s like I can’t shut off my brain.”) Some women can fall asleep but then wake up even before the baby cries; they sometimes report worrying that the baby will cry and they won’t be able to soothe or comfort him.
Most women with depression during pregnancy or the postpartum period report at least some anxiety as well. This can take the form of worrying too much or having anxiety attacks (also called “panic attacks”). This is a normal part of perinatal depression, and can be treated along with the depressive symptoms. (See below for treatment options.) Many women with postpartum depression report “scary thoughts” that pop into their mind all of a sudden. These are often pictures or images of something bad happening to the infant (or a sibling) that are distressing to the woman. These do not mean that she wants to act on these thoughts or hurt the child in any way. They can be a normal part of postpartum adjustment for many women, occurring a few times after birth, but often occur more frequently when depression or anxiety sets in.
It’s important to talk to your doctor, midwife or therapist if you are having these thoughts, because they are distressing and can become more frequent if not treated appropriately.
Women with depression can have thoughts about suicide and act on them. Some women may have passive thoughts, such as “things would be better off if I were gone” or “it would be okay if I didn’t wake up tomorrow.” Others may actively think about ways to hurt themselves, or have the “scary thoughts” mentioned above that involve pictures of hurting themselves. These are all signs of more severe depression that needs to be treated immediately by a doctor. Some women don’t report these thoughts out of fear that they will be stigmatized or hospitalized.
It is important to remember that the most important thing is to get help, so you can go back to feeling like yourself again.
If you are having active thoughts of suicide, please call 1-800-944-4PPD or 1-800-PPD-MOMS, or 911 to get immediate help.
As previously mentioned, anxiety seems to be a common symptom among all disorders during pregnancy and postpartum, and will often be present along with depression. However, some women will have what are called “primary anxiety disorders,” which are mostly anxiety, but may have some mild depressed mood as well. Women with a pre-existing anxiety disorder may also worsen at this time. Panic attacks can occur for the first time in pregnancy or the postpartum period. Panic disorder involves full-blown panic attacks that involve suddenly feeling physical symptoms such as heart palpitations, hot or cold flashes, chest pain, shaking, dizziness, and also feeling very worried or scared of losing control or going crazy. These attacks are marked by a sudden increase in anxiety and may include many or some of these symptoms. These can start off happening in response to a “trigger” (such as baby crying uncontrollably) but can get worse and occur even when there isn’t anything stressful going on.
Other women develop excessive worrying during pregnancy or the postpartum period. Some of these women have always been “worriers,” but for others this can be new. Women who are pregnant often worry excessively about their own health, the baby’s health, and how labor and delivery will occur. Postpartum women tend to worry excessively about the baby’s health, and may change their behavior as a result: staying up at night to watch the baby sleep (even when she is exhausted herself), waking up at night to check on the baby, not leaving the house because of germs or worrying that the baby might cry. For other women, breastfeeding can cause severe anxiety with fears about milk supply and baby’s weight gain occupying their mind all of the time.
The development of postpartum obsessive-compulsive disorder and obsessive-compulsive symptoms can also occur during the postpartum period. These symptoms may occur with or without postpartum depression. Some women with postpartum OCD feel a need to clean obsessively, wash their hands excessively and even avoid leaving the house out of fear of germs. (“I spend hours washing her bottles to make sure they are clean.”) This is an example of the “compulsive” part of OCD—feeling an overwhelming need to perform an activity, and then feeling calmer once it is done.
Other women experience the “obsessive” part of OCD with sudden pictures or thoughts that pop into their minds and are disturbing. This can be a picture of something happening to the baby, a sibling, or herself. These thoughts can be very distressing to the woman and are not something she wants to act on. They can be a normal part of the postpartum period in many women (occurring a few times after birth), but in some women with postpartum depression or postpartum OCD they can occur several times daily and lead to avoiding things that trigger the thoughts, which can sometimes be the baby himself.
This is the most severe postpartum disorder and afflicts approximately 1 – 2 per thousand new mothers. This is usually an early manifestation of Bipolar Disorder, rather than Schizophrenia. The onset of postpartum psychosis (PPP) is usually early, within the first three weeks after childbirth. The symptoms may include hearing voices or noises (hallucinations), becoming preoccupied with religious symbolism or conspiracies, and having thoughts of hurting oneself or the baby out of an irrational kind of thinking (delusions). Women with PPP may appear normal for periods of time, then become disorganized (wearing inappropriate clothing, cleaning the house with coffee grounds, not making sense in conversation). If you suspect PPP, this is an emergency and the woman must go to an Emergency Room immediately, as she is at high risk for hurting herself or her infant.
What causes Perinatal Mood and Anxiety Disorders?
Researchers don’t have a full understanding of the cause of Perinatal Mood and Anxiety Disorders. There does seem to be a group of women who are more sensitive to hormonal changes and are therefore at higher risk for mood or anxiety disorders during pregnancy or postpartum. These women tend to have more mood symptoms around their menstrual cycle and may have family members with a history of Perinatal Mood and Anxiety Disorders. Having a history of depression or anxiety also puts a woman at risk for a Perinatal Mood or Anxiety Disorder, which is likely related to hereditary and biologic factors. Environmental stresses also play a role, and women with minimal social support and severe life stresses are also at higher risk.
The most important thing to know is that Perinatal Mood and Anxiety Disorders don’t happen because a woman is a “bad mother” or not a good person. They are biological and hereditary illnesses that need to be taken seriously and treated. They are the most frequent complication of childbirth.
Fathers can experience a Perinatal Mood or Anxiety Disorder as well. A study in the Journal of the American Medical Association  showed that over 10% of new fathers experienced some level of depression during pregnancy or after the birth of a child. It has also been shown that fathers who are significantly involved in the care of a newborn have hormonal changes, specifically a drop in testosterone, which indicates how significant an effect the birth of a child can have on a parent.
 Paulson J and Bazemore S. “Prenatal and Postpartum Depression in Fathers and its Association with Maternal Depression.” JAMA 2010; 303(19):1961-1969.
How long do Perinatal Mood and Anxiety Disorders last?
The good news is that with appropriate treatment, postpartum disorders are only temporary. Depending on the degree of severity and treatment modality, postpartum depression can last from a few months to up to a year. Untreated, these disorders and symptoms can last for 3-4 years in some women.
Research has shown that a mother’s untreated mood or anxiety disorder can negatively affect her child’s cognitive, physical and emotional development. However, getting effective treatment can reverse these effects, according to a recent national study.
 Wickramaratne et al. Children of Depressed Mothers 1 Year After Remission of Maternal Depression: Finding from the STAR*D CHILD Study. Am J Psychiatry 2011;168:593-602.
How do I get help?
If you believe that you may be experiencing a perinatal mood or anxiety disorder, it is important to contact your doctor immediately and discuss your symptoms. If you are postpartum and having symptoms for the first time, or symptoms that are different from previous episodes, your doctor may want to check your thyroid function with a simple blood test. Low thyroid function can mimic many of the symptoms of depression.— There are two main methods of treating perinatal mood and anxiety disorders: therapy and medication. Therapy is almost always an important component of treatment, regardless of how severe the symptoms might be. Talking about your symptoms with a trained counselor has been shown to be an effective treatment in multiple studies on perinatal mood and anxiety disorders, and has no risk to mother or child.— The counselor should be someone who has experience in evaluating and treating perinatal mood and anxiety disorders, and is sensitive to the issues faced by parents around childbirth. Postpartum Health Alliance maintains an online directory of therapists who are specially trained in this topic.— Psychotropic medications can also be helpful in treating some women with perinatal disorders, and women with moderate to severe symptoms often recover more quickly with their use. Medications should be prescribed by a physician who is able to have a thorough discussion with you about the risks, benefits and alternatives to their use. Information about medication use in pregnancy and breastfeeding can also be found at mothertobaby.org or by calling 1-866-626-6847.— Research has shown that acupuncture as well as exercise can also be helpful in treating mild mood and anxiety disorders.
What if my problems are minimalized or trivialized?
Unfortunately, some health care providers may not receive adequate training in how to recognize and treat perinatal disorders. If, after any professional guidance, you find yourself still in the same situation, stop and listen to your instincts. You know yourself better than anyone else. Don’t give up – Postpartum Support International can help point you toward resources and professionals that are educated about perinatal mood and anxiety disorders in your area. Go to postpartum.net or call 1-800-944-4PPD.