Perinatal Mental Health Series, Part 1: Increasing Awareness and Reducing Barriers to Effective Treatment
April 16, 2024 By Ellen Bee, LCPC and Mackenzie Conner, LPC
This article, co-authored by Ellen Bee, LCPC and Mackenzie Conner, LPC, is the first in a series of articles that we will be sharing on the topic of Perinatal Mental Health. If you believe you or a loved one may be experiencing a perinatal mental health condition, please seek help. Here is a list of credible support resources: [PMH Resource List].
According to the World Health Organization (2020), nearly 10% of pregnant individuals and 13% of individuals who have recently given birth experience a diagnosable mental health condition. Despite the widespread occurrence of perinatal mood disorders, concerns about stigma lead many birthing parents* and their partners to under-report symptoms, furthering the gap in access to evidence-based, cost-effective, and human rights-centered mental health services. Additional barriers, such as systemic and interpersonal racism in healthcare, as well as financial and logistical stressors for new parents, contribute to elevated risks of birthing parent and infant mortality. Naturally, infant health is prioritized, yet many communities fail to recognize that perinatal mental health extends far beyond the birthing process and parental well-being is imperative to healthy family development.
What is perinatal mental health and why does it matter?
Broadly, perinatal mental health encompasses the emotional and psychological well-being of individuals during the perinatal period, which includes pregnancy through the first year of giving birth (Postpartum Support International, 2022). During the perinatal period, individuals may experience a wide range of emotions and psychological changes. While some mood fluctuations are considered normal, due to hormonal shifts and the challenges of adapting to parenthood, some individuals may experience more clinically significant mental health issues, such as depression, anxiety, or other mood disorders.
Promoting adaptive perinatal mental health entails normalizing the spectrum of emotions experienced by birthing parents and their partners, facilitating greater awareness and recognition of symptoms of perinatal mood and anxiety disorders (PMADS), and creating better access to effective mental healthcare. Early intervention during the perinatal period can help mitigate the risks of developing chronic mental health issues for parents and also reduces the risk of other adverse outcomes, such as preterm birth or low birth weight (Postpartum Support International, 2022). Prioritizing perinatal mental health not only improves the quality of life for birthing parents and their partners, but also fosters healthier families and communities. Building awareness and encouraging early interventions strengthens parent-child interactions, supports child development, and promotes overall family well-being.
What is the difference between the “baby blues” and perinatal mood and anxiety disorders (PMADs)?
The “baby blues” refer to a common and temporary emotional state experienced by many parents after giving birth. This phenomenon typically manifests within a few days following childbirth and can last for up to two weeks (Postpartum Support International, 2022). Symptoms of the baby blues may include mood swings, tearfulness, irritability, anxiety, and difficulty sleeping. These feelings are often linked to hormonal changes, fatigue, and the stress of adjusting to parenthood. While the baby blues can be challenging, they are considered a normal and self-limiting response to the physical and emotional demands of childbirth and the postpartum period. With adequate support and self-care, the symptoms of the baby blues usually resolve on their own without the need for intervention.
In contrast, perinatal mood and anxiety disorders (PMADs) encompass a spectrum of mental health conditions that can emerge at any time during or after pregnancy, including after experiencing pregnancy loss, and within the first year postpartum (Postpartum Support International, 2022). These disorders include conditions such as postpartum depression, postpartum anxiety, perinatal panic disorder, perinatal obsessive-compulsive disorder, perinatal bipolar disorder, postpartum post-traumatic stress disorder, and postpartum psychosis. Symptoms of PMADs can include:
- Feelings of hopelessness, guilt, or shame
- Feelings of anger, rage, irritability, or scary unwanted thoughts
- Sleep disturbances, such as sleeping too much or feeling “too wired” to sleep
- Loss of appetite or weight loss
- Intrusive, unwanted thoughts and worries of “what if” scenarios
- Excessive worry over the baby’s health and safety
- Lack of interest in the baby or difficulty bonding with the baby
- Loss of interest in activities that were previously pleasurable
- Physical symptoms like dizziness, hot flashes, or nausea
- Possible thoughts of harming the baby or yourself
PMADs can vary in severity and can significantly impact a parent’s ability to function, care for themselves and their newborn, and maintain healthy interpersonal relationships. Mood and anxiety symptoms experienced by a birthing parent can also directly affect their partner and relationship. Partners may experience feelings of overwhelm, confusion, anger, and fear regarding the well-being of their significant other, causing potential strain to a couple’s relationship. In fact, research indicates that approximately 10% of new fathers face challenges related to depression, mood, or anxiety (Paulson & Bazemore, 2010).
It is essential to recognize that PMADs are common and treatable and to seek professional help if symptoms persist or worsen. Healthcare providers can assess and provide appropriate support, offering a pathway to effective intervention and treatment as well as improved outcomes for both parents and their family.
Who is at risk for developing PMADs?
While perinatal mood and anxiety disorders can affect individuals of any race, age, gender, or income status, certain factors pose increased risk. These include a personal or family history of mental health conditions, a lack of support from partners, family, or friends, experiencing stressful life events during pregnancy or shortly after childbirth, complications during pregnancy or childbirth, hormonal changes, sleep deprivation, and challenges adjusting to parenthood (Davis, 2022). Additional circumstances, such as financial strain or limited access to healthcare, may exacerbate symptoms, but perinatal mood disorders can occur with or without added life stressors.
Recent research has also indicated that modern birthing parents are currently navigating circumstances markedly different from those of previous generations. This shift can be attributed to various factors, including the rapid pace of modern life, advancements in technology, the pervasive use of social media (which has the potential to amplify stigma and experiences of abuse or bullying), increased feelings of isolation, and insecure employment (Howard & Khalifeh, 2020). Furthermore, findings from a multi-generational pregnancy cohort study indicated that depression in pregnancy was 51% more common among younger birthing parents than it was among birthing parents 25 years ago (Howard & Khalifeh, 2020). This suggests a generational increase in the incidence of mental health concerns during pregnancy, underscoring the importance of addressing the unique challenges faced by birthing parents in contemporary society.
Additional risk factors for developing PMADs should be considered from a macro-level perspective, including acknowledgement of the health impacts of institutionalized biases against marginalized populations. These factors include, but are not limited to: race, socioeconomic status, sexual and gender identity, and marital status (e.g., single or unmarried parents). Women of color are less likely to be screened for PMADs, yet in a study of 10,000 women, African American mothers were more likely to score higher for PMADs when properly assessed (Wisner et al., 2013). Additionally, women of color are more likely to encounter microaggressions in medical spaces, creating additional barriers to receiving supportive care and building trust with care providers.
Pre-pregnancy factors that may increase risk for developing PMADs include genetics, previous psychiatric history, adverse childhood experiences (ACES), and an absence of social support prior to giving birth (Guintivano et al., 2019). Research also demonstrates a strong relationship between increased risk for developing PMADs and previous psychiatric history, including anxiety, major depressive disorder (MDD), other mood disorders, personality disorders, previous history with PMADs, and other psychiatric concerns (Guintivano et al., 2019). Indeed, family or previous individual history with psychiatric disorders is one of the strongest and repeatedly validated predictors for developing PMADs (Guintivano et al., 2019).
Current research suggests that postpartum depression (PPD) has a heritability of about 50%, suggesting an increased risk of development of PPD if a parent experienced PMADs during or after their pregnancy. Reported family history of postpartum mood disorders in a mother or sister steeply increases the risk for developing PMADs by double or triple (Jones & Craddock, 2001). Family history of postpartum psychosis in a mother or sister further increases risk by nearly five times (Payne et al., 2008).
Despite these findings, individual or family history with psychiatric conditions and PMADs do not determine perinatal mental health outcomes with certainty, nor do they predict the ability to be a loving parent. With proper screening, knowledge of family and personal and mental health history, and meaningful support, risk factors can be effectively mitigated.
Reducing stigma and challenging societal norms around parenthood
Despite the relatively high incidence of PMADs, many birthing parents are reluctant to disclose symptoms or access mental health treatment, due largely to the perceived stigma associated with mental health conditions. Research in this area is unfortunately limited, but studies suggest that parents feel discouraged from seeking help due to fears of being judged, as well as internalized myths that an unhappy parent is a “bad” parent. Other cultural narratives of parenthood that deepen shame include feeling like a failed parent, pressures to mask challenges, and the overall societal silencing of negative parenting experiences (Law et al., 2021). Given the substantial adjustments required during the postpartum period, including changes in roles, routines, and responsibilities, the suppression of negative experiences surrounding pregnancy and parenthood only serves to perpetuate perinatal mental health challenges.
Medical discourse that highlights the potential risk posed to the child by the birthing parent’s mental illness may inadvertently contribute to parents’ hesitancy to seek support, by diminishing the significance of the parent’s own experiences and contributing to the shame many parents feel around experiencing PMADs.
Evidence-based treatment options
Ultimately, perinatal mental health is a multifaceted issue that requires a comprehensive approach, including increased awareness and education, screening, and access to appropriate mental health supports and services. Prioritizing perinatal mental health contributes not only to the health and happiness of individual parents, but also to the well-being of their growing families. Imperatively, perinatal mental health treatment occurs both during pregnancy and the postpartum period, with early intervention yielding the most effective outcomes for parents and their families.
Current treatment recommendations include, but are not limited to, the use of Cognitive Behavioral Therapy (CBT), Interpersonal Psychotherapy (IPT), couples therapy, and group therapy. In addition to symptom management, therapeutic goals may include grief processing, addressing the stress of adjusting to parenthood, strengthening relationships, and buffering support. Treatment should include both support for the birthing parent and intervention within their support systems (e.g., partners, supporters, and environment), in order to create comprehensive and sustainable well-being.
The experience of bringing home a child, either as a first time parent or one within a multi-child family, can be overwhelming and full of emotions, even under the best of circumstances. For parents experiencing the added stress of navigating PMADS, receiving effective support without judgment is critical to setting parents and families up for success in this period of heightened stress and change. Thanks to research and advocacy work in this area, we now know that PMADS are both prevalent and treatable. We also know that perinatal mental health concerns are not a product of “doing something wrong,” nor do they determine one’s competence to care for and love a child. Whether seeking support for yourself or a loved one, there are resources and expertise available to help you through this experience, and you do not have to carry this alone.
References
Davis, W.N. (2022). Perinatal mood and anxiety disorders: symptoms, causes, and risk factors. Postpartum Support International and 2020 Mom Maternal Mental Health Webinar Certificate Training.
Guintivano, J., Manuck, T., & Meltzer-Brody, S. (2018). Predictors of postpartum depression: A comprehensive review of the last decade of evidence. Clinical Obstetrics and Gynecology, 61(3), 591–603. https://doi.org/10.1097/GRF.0000000000000368.
Howard, L.M. & Khalifh, H. (2020). Perinatal mental health: A review of progress and challenges. World Psychiatry, 19(3), 313-327.
Jones I, Craddock N. Familiality of the puerperal trigger in bipolar disorder: Results of a family study. The American Journal of Psychiatry. 2001;158(6):253–64.
Law, S., Ormel, I., Babinski, S., Plett, D., Dionne, E., Schwartz, H., & Rozmovits, L. (2021). Dread and solace: Talking about perinatal mental health. International Journal of Mental Health Nursing, 30(9), 1376-1385.
Paulson, J.F. & Bazemore, S.D. (2010). Prenatal and postpartum depression in fathers and its association with maternal depression: A meta-analysis. JAMA, 303(19), 1961-1969.
Payne, J.L., Mackinnon, D.F., Mondimore, F.M., Mcinnis, M.G., Schweizer, B., Zamoiski, R.B., et al. Familial aggregation of postpartum mood symptoms in bipolar disorder pedigrees. Bipolar Disorders. 2008;10(1):38–44.
Postpartum Support International. (n.d.). Learn more. Retrieved from https://www.postpartum.net/learn-more/.
Wisner, K. L., Sit, D. Y., McShea, M. C., et al. (2013). Onset timing, thoughts of self-harm, and diagnoses postpartum women with screen-positive depression findings. JAMA Psychiatry, 70(5), 490-498.
World Health Organization. (n.d.). Maternal mental health. Retrieved March 12, 2024, from https://www.who.int/teams/mental-health-and-substance-use/promotion-prevention/maternal-mental-health.
* The term “birthing parent” is an inclusive way of referring to individuals who give birth, regardless of their gender identity. Traditionally, the term “mother” has been used exclusively to describe someone who gives birth. However, not all individuals who give birth identify as female or as mothers. Some may identify as transgender men, non-binary, or genderqueer individuals, among other gender identities. Using the term “birthing parent” acknowledges the diverse range of identities and experiences among those who give birth. It recognizes that individuals of various genders can experience pregnancy and childbirth and affirms their identities and experiences. Additionally, it helps to avoid assumptions about gender and parenthood, promoting inclusivity and respect for all individuals involved in the birthing process.
