10 essential facts about postpartum depression

by Aga Grabowski

1. Postpartum depression represents only one of a number of disorders experienced by women in pregnancy and postpartum.

They are collectively known as perinatal mood and anxiety disorders (PMADs).  Not knowing that mental health disturbances in the postpartum can encompass symptoms such as agitation, anger, anxiety, obsessive thoughts and others, new moms who call our practice frequently report being confused about what they are experiencing.  “I am not depressed,” we hear from them, “but something feels wrong.”  

Anxiety is particularly common in the postpartum. Women report feeling irritable, overwhelmed, even angry.  They may worry and ruminate and have panic attacks. Insomnia – not being able to fall asleep or remain asleep even when baby is sleeping – is another common symptom. Women may develop scary, obsessive thoughts of harm coming to their baby or of causing harm to the baby. Some new moms who have experienced their childbirth as traumatic go on to develop symptoms of PTSD.  

In other words, sadness and lack of energy are just a few of many symptoms that can develop in the first postpartum year.  What is important to remember is that postpartum depression itself rarely conforms to our stereotypical notion of depression as characterized by a flat, persistently low mood. Depression in the postpartum tends to be more agitated and feel like an up and down rollercoaster of emotions.

2. Every new mother will at times (read: frequently!) feel overwhelmed by demands of new motherhood, but there is a clear distinction between very normal negative emotions and thoughts that accompany this transition and symptoms that require professional help.

Frequently, the reason why women wait to get help or don’t get help at all has to do with the erroneous belief that their symptoms are a normal facet of their new reality. Admittedly, it can be very difficult to figure out whether the emotional rollercoaster of new motherhood represents normal adjustment or if something more serious is taking place. Severity and duration of negative emotional experience are two important factors we take into account as mental health professionals when making this determination. If a woman reports to us “I am not myself”, which is a frequent statement we hear from women suffering from PMADs, this alerts us to the possibility that her negative emotions are impairing her functioning and constraining her ability to enjoy her life and baby.  If negative emotional experiences are fleeting, do not persist and upon resolving allow a woman to tap into a sense of calm and enjoyment, likely what she is experiencing is normative and does not require professional attention.

Certain signs make the need to seek help very clear. These are: sleeping disturbances unrelated to the need to care for the baby (not being able to sleep when the baby sleeps); persistent anxiety (worry, rumination, obsessive thoughts) and/or sadness, persistent guilt, hopelessness, thoughts of escaping; feeling disconnected from the baby; changes in appetite; lack of enjoyment and motivation; thoughts of self-harm, suicide or death.

3. With the right treatment, women get better.

Mental health treatment for PMADs works! Part of the reason why we love working with women who are pregnant or postpartum is that it is such a joy and privilege to see them become themselves again, find happiness in their lives and families. In cases where symptoms are mild to moderate, psychotherapy tends to be sufficient. In more severe cases, pharmacological treatment may need to be considered in addition to psychotherapy.  Both pharmacological and psychotherapeutic treatment require that women be seen by specialists in women’s reproductive mental health who stay abreast of the latest research and utilize evidence-based approaches that have the highest potential to help women quickly. The bottom line is that treatment is the best gift a suffering woman can give herself and her family.

4. Postpartum blues does not last longer than 2 weeks.  Not all emotional reactions experienced in the first two weeks after childbirth can be ascribed to postpartum blues.

Often women and their medical providers incorrectly ascribe serious postpartum mood disturbances to postpartum blues. Postpartum blues is a normal experience reported by the vast majority of new mothers in the first two weeks following childbirth. It is thought to stem from rapid hormonal changes as well as the stress of birthing and the overall psychological and physical demands of the transition to parenthood. What is critical to remember is that a woman experiencing the blues is more irritable, tearful, and vulnerable to mood swings, but she is also happy or at peace most of the time. Her ability to function is not impaired. Blues tends to peak at 3-5 days postpartum and lessen over time, going away within two weeks of delivery. If a woman had a baby a few days ago and feels persistently and severely sad or anxious, this likely is not postpartum blues but something more serious. Again, the key distinction is that women with the blues have moments of irritability, tearfulness and feel overall more reactive, but are able to return to a happy, contented baseline and function is unimpaired. When in doubt, it is best to reach out to a professional who can provide further assessment.     

5. Screening positively on a mood questionnaire such as the Edinburgh Postpartum Depression Scale does not automatically mean that a woman is depressed.

In Illinois, obstetricians and pediatricians are required to invite pregnant and postpartum women to complete a mood questionnaire such as the Edinburgh Postpartum Depression Scale or the Patient Health Questionnaire. This screening is meant to yield information about a woman’s mental health but not provide a mental health diagnosis. A woman who scores highly on it does not necessarily have depression. High scores simply mean that further assessment is needed and that the woman should possibly be referred to a mental health specialist. It is critical that women answer the screening questions truthfully – if they need professional treatment, obtaining it as soon as possible usually leads to a quicker and easier recovery. 

6.  Symptoms of depression and/or anxiety frequently begin in pregnancy.

PMADs are common in pregnancy and not just the first postpartum year. Postpartum depression is a misleading term since it not only does not capture the range of symptoms women experience but also suggests that mental health issues develop only AFTER the baby is born. Yet up to 20% of pregnant women are affected by PMADs. Being anxious and/or depressed in pregnancy significantly increases the risk of developing postpartum mood disturbances. At Wildflower, we find that women who are struggling in pregnancy and seek out psychotherapy tend to fare better in the postpartum than women who come to us once the baby was born and report that they struggled in pregnancy as well. While we cannot promise that psychotherapy in pregnancy will prevent symptoms in the postpartum, women who do see a psychotherapist in pregnancy feel more prepared and able to cope with challenges of the transition to parenthood when they have learned effective coping techniques, increased their social support networks, and created solid self-care routines prior to baby’s arrival.

7. In the postpartum, symptoms do not necessarily develop soon after birth. They can develop in the months that follow.

Symptoms of a postpartum disorder may begin right after birth but may also not start until several months later. Symptoms tend to peak between three to six months postpartum. There are varied reasons for delay in symptom onset, such as significant, unexpected stressors, sudden weaning or resumption of periods, and illness.

8. Untreated, PMADs often become chronic. The consequences can be serious.

It is never a good idea to “power through” PMADs and not seek treatment. Untreated, PMADs can become chronic. These disorders not only impair a mom’s ability to function in everyday life and enjoy this time, but the longer they last, the higher the risk of aversive outcomes for the mother, her partner, and child(ren).  

PMADs can have negative implications for the mother’s ability to parent sensitively, effectively, and bond well with her baby. Children of depressed/anxious mothers are at a higher risk of developing problems in cognitive, social, and emotional development. Untreated symptoms in pregnancy can lead to pre-term delivery and baby’s lower birth weight.  The risk for infanticide and/or suicide is increased with PMADs. Suicide is a leading cause of maternal mortality.  Lastly, partners of afflicted women are also at a higher risk of developing mental illness.  The bottom line is that it is critical to seek treatment as all these risks can be greatly mitigated.

9. Women who are suffering often don’t look like they are.

Pregnant and postpartum women who are struggling with PMADs often go to great lengths to mask their symptoms. Just because a woman has done her hair and has make up on does not mean that she is doing well. We need to not make assumptions about women’s wellbeing based on their appearance but sensitively and genuinely inquire about how they are feeling. At Wildflower, we remind all women and their partners that they are not to be blamed for their symptoms. PMADs can happen to anyone, regardless of whether they have a history of mental illness or not.   

10. New dads are at risk of developing symptoms as well.

Although fathers do not experience the same hormonal shifts that are thought to play a role in perinatal mood and anxiety disorders, they too are susceptible to mental illness in the transition to parenthood. About 10% of new dads have depression, mood, or anxiety problems. The risk is increased for fathers whose partners are suffering from PMADs. At Wildflower, we are glad to see that dads are increasingly willing to seek support in this challenging time. Often they report that the initial step of reaching out is the most challenging part of starting psychotherapy due to stigma as well as internalized expectation that they be “strong” and not show emotion.