Content Warning: This article includes references to suicidal ideation, intrusive thoughts, and other mental health challenges.
Please note that while most of the research refers to birthing mothers as it relates to peripartum and postpartum mental health challenges, nonbirthing parents can also experience many of the same difficulties.
I desperately wanted to be a mother ever since I was a child. I had a baby doll (the kind that you feed some gross mushy stuff, only to have it come out of the other end, into diapers… or not), and I would hold it and rock it and tend to it. I even gave us matching tattoos using a Sharpie. Mine eventually washed off, but the one on the baby stayed put. I was so eager to be connected to another and have someone to care for.
I was overjoyed when I was fortunate enough to be pregnant with my first. I was living in a one-bedroom apartment with my partner and had just quit my full-time job to build my practice after years of working multiple jobs. So no, I wasn’t financially prepared and certainly didn’t have a Pinterest-perfect nursery. But I thought I was prepared emotionally. I had spent years working with children: as a nanny, a tutor, an afterschool provider, a teacher’s aid, and a family therapist. I had even spent a year helping with the care of my nephew after his birth, so I really thought I was ready. But nothing could have prepared me for the dark months to come.
My pregnancy wasn’t easy, but it wasn’t terribly difficult either. The emergency c-section was certainly challenging, and for weeks, it was difficult to sit up or walk. And then, for months, I felt like a shell of a human. Of course, I wasn’t sleeping or really spending time with other adults, and none of that helped. I went back to work after six weeks. While it was hard to be away from my baby, it meant that I had to shower and put on my outside clothes, and I got to do something that allowed me to feel competent, which was precisely the opposite of how I felt when caring for my infant.
I didn’t realize the extent of my suffering for months, even as a trained mental health therapist, even as someone who had struggled with depression and anxiety since adolescence. At one point, I remember telling my partner that he should consider marrying my cousin once I was gone. She was eager to be a mother, and I thought my daughter would be better off without me. I wasn’t actively thinking about dying by suicide, but at the time, I just couldn’t imagine myself surviving. It was just too much, too demanding, too impossible, and I was convinced I was failing and that my baby was suffering because of it.
At some point, I met with a doctor who had been developing a gadget to help babies sleep. My involvement was initially market research, but he had me complete a list of questions about my mental health, and he recognized my postpartum depression. He saw my suffering, and to finally be seen was the first step in my recovery as it allowed me to see myself. I went back to therapy, and I tried to pay attention to what I needed. My path through wasn’t linear; it wasn’t easy, but it was worth it.
My postpartum experience after my second was different. Again, I thought I was prepared. I had secured help I could trust and was more explicit about my need for time for myself and support from loved ones. And then, when my baby was here, I had scary thoughts all the time. I worried I would drop her or that her stroller would escape from my hands down the hill and into oncoming traffic. I imagined someone breaking into the house and trying to hurt my children, and I imagined myself trying to defend them but being unsuccessful. I was exhausted but couldn’t sleep, and I would check to make sure the baby was breathing and then check again.
This time, I shared my concerns with my therapist and tried to access support. My well-meaning therapist wasn’t familiar with postpartum mental illness and encouraged me to drink tea before bed and to reduce my exposure to scary television shows. It took me a while to understand what I was struggling with and to address my postpartum anxiety for what it was, but I was able to move through it. It took a lot of time and a lot of work, but eventually, I was able to be more present with my child and access the support I needed.
What Are The Postpartum Mental Health Issues?
While research tells us that Postpartum Depression (PPD) is the most common psychiatric complication of childbirth, affecting 10% to 15% of women who have recently given birth, it is not a diagnosis in The Diagnostic and Statistical Manual of Mental Disorders (DSM) V (what many refer to as the bible of mental illnesses). Neither are Postpartum Anxiety or Postpartum Psychosis. And yet, many parents endure different symptoms that are either related to the peripartum (during pregnancy) or postpartum (after childbirth) period.
In the current DSM, a parent experiencing peripartum or postpartum challenges could be diagnosed with Major Depressive Disorder, Generalized Anxiety Disorder, or Depressive Disorder with anxious distress or peripartum onset. The DSM V expressly writes, “Fifty percent of “postpartum” major depressive episodes actually begin prior to delivery. Thus, these episodes are referred to collectively as péripartum episodes. Women with péripartum major depressive episodes often have severe anxiety and even panic. Prospective studies have demonstrated that mood and anxiety symptoms during pregnancy, as well as the “baby blues,” increase the risk for a postpartum major depressive episode.” The DSM V also includes the statement, “Peripartum-onset mood episodes can present either with or without psychotic features.” The other diagnosis that relates to the postpartum period is Brief Psychotic Disorder with the additional specifier of postpartum onset.
For most people struggling or suffering before or after childbirth, the specific naming of a diagnosis likely doesn’t matter as much as what they’re experiencing and their need for support and relief. However, the fact that the only references to postpartum and peripartum mental health in the DSM are through specifiers and in the fine print can make recognizing and understanding these issues even more difficult. While generally, anxiety and depression are understood as two separate diagnoses, even when we realize the relationship between the two, according to a lot of the literature on depression with peripartum or postpartum onset, includes symptoms that we would otherwise associate with anxiety. This further confuses things and can make it easier to miss postpartum issues.
For the sake of this article, we are going to discuss postpartum depression and anxiety and will also refer to postpartum psychosis to explore the different experiences. We hope to shed light on these issues to make understanding and managing them easier.
What is Postpartum Depression?
Postpartum depression (PPD) is a mental health condition that occurs in birthing parents (and some non-birthing parents). It is generally characterized by feelings of extreme sadness, worthlessness, anxiety, hopelessness, irritability, guilt, and/or isolation. Many people report feeling disconnected from themselves and their newborns during their experience of PPD. Postpartum Support International also names that in some cases of the condition, a new parent may think about harming themselves or the baby. While the symptoms of PPD are the same as with a more general depression, with PPD, they are usually cited as being related to the pregnancy or baby. Additionally, with PPD, the onset can be pregnancy or months after delivery.
How Does Postpartum Depression Differ From Baby Blues?
The Baby Blues, while challenging, are a common and temporary phenomenon. Postpartum depression, on the other hand, is a more severe and persistent mental health condition. Baby blues typically begin within a few days after childbirth and can last up to two weeks, which is considered a standard adjustment period. While the symptoms of the baby blues and postpartum depression are the same, it is the intensity that differs. Baby blues are more manageable, and postpartum depression can significantly impair daily functioning.
What is Postpartum Anxiety?
One often-cited research article states, “Postpartum anxiety is less well known, and less scientifically studied, than postpartum depression.” The same report expresses that at least 10% of women experience high postpartum anxiety, and that generalized anxiety (GAD) and obsessive-compulsive disorder (OCD) are the most common types.
When it is discussed, postpartum anxiety (PPA) is defined as characterized by excessive and persistent worry and fear, particularly related to the well-being of the baby. PPA involves intense and intrusive thoughts that can interfere with daily functioning. Individuals with postpartum anxiety may experience restlessness, racing thoughts, muscle tension, and physical symptoms such as headaches and stomachaches. They may exhibit behaviors like excessive checking on the baby, difficulty relaxing, and avoidance of situations that trigger anxiety. Irritability, an overwhelming need for control, and fear of being alone with the baby or away from the baby are also common emotional aspects of postpartum anxiety. And for those with OCD symptoms, they may also engage in rituals or experience compulsions to try to prevent harm to their babies.
What is Postpartum Psychosis?
Research conveys that postpartum psychosis (PPP) is not as common as PPD and PPA and has severe and potentially life-threatening symptoms that can emerge in the days to weeks following childbirth. PPP is characterized by hallucinations, delusions, extreme mood swings, confusion, and/or disorganized thoughts. Individuals experiencing postpartum psychosis may exhibit erratic behavior, have difficulty distinguishing reality from delusions, and may be at risk of harming themselves or their babies.
Why Do Peripartum and Postpartum Mental Health Challenges Occur?
Peripartum and postpartum mental health challenges can affect any parent, regardless of age, socioeconomic status, or cultural background. That said, various psychological, hormonal, and environmental factors have been found to contribute to the development of these conditions. For many new parents, the adjustment to life with a newborn can take an immense toll on their mental health. From middle-of-the-night feedings to colic to sleepless nights, living with a new baby can be incredibly stressful. Add to that, financial stressors, a lack of support, and the relationship challenges that many new parents face, and it stands to reason that peripartum and postpartum mental illness is so prevalent. According to current estimates, about 1 in 7 people are liable to develop PPD throughout their lifetimes.
As previously mentioned, hormones can also play a large part in the development of peripartum and postpartum mental illnesses. Doctors have yet to determine why some people develop the conditions over others, but it is thought to be linked to fluctuations in hormone levels after birth. After childbirth, many people experience a rapid decline in estrogen and progesterone, which can both be attributed to an increase in depressive symptoms and irritability, respectively.
According to the Mayo Clinic, several common risk factors have been found in peripartum and postpartum mental illnesses. Prior history of family history of mental health conditions like depression or bipolar disorder makes it more likely that a new parent will develop a mental illness. Having had a peripartum or postpartum mental illness during or after a prior pregnancy also increases that risk. Pregnancy complications and experiencing difficulty breastfeeding play a role as well. A study that surveyed 1.1 million women worldwide was able to determine that those with the most increased risk of developing PPD were new mothers, mothers under 25, and mothers of twins. Mothers over 40 who had just given birth to twins were found to be at the highest risk, however.
And, of course, one’s environment is always a factor when it comes to mental health. While every parent deserves to go home from their delivery to a peaceful, supportive, and well-functioning environment, that is certainly not the case for many parents. The strain of increased responsibilities, challenging family dynamics, and a general lack of social support for new parents can only serve to exacerbate an individual’s postpartum mental health and increase the likelihood that they will struggle.
Why is There a Stigma Around Peripartum and Postpartum Mental Illnesses?
Even though parenthood is a complex and immensely challenging endeavor, society often affords new parents little margin for error. Many women feel as though they have to have some instinct kick in that tells them exactly how to be the best mother to their child, and they often feel a lot of shame and guilt when this doesn’t happen naturally. As such, too often, new parents aim to hide it if they’re not doing well after the birth of their baby. Studies have found that as many as 58% of women experiencing PPD will not seek help for their condition, with many reporting that they were too scared to reach out for support.
It’s important to acknowledge that much of the stigma surrounding peripartum and postpartum mental illnesses is facilitated by a society and, in particular, a healthcare system that is rooted in misogyny. Women have long been regarded as poor historians when it comes to their own health, and this is especially true of their reproductive and mental health. For a time, it was inconceivable that a new mother would feel anything but joy in response to the opportunity to fulfill what was widely thought of as their purpose: to have children. As a result, too often, mothers who struggled were disregarded entirely or, worse, met with disdain. And while the medical community has made progress in recognizing peripartum and postpartum-specific challenges, they are still not fully understood or recognized, and often go undetected. The fact that so many don’t seek help for their mental health is, in part, linked to this legacy.
How Can I Manage My Mental Health Peripartum and Postpartum?
If you’ve had a baby and you’re not feeling like yourself (more depressed, anxious, irritable, etc) after more than two weeks postpartum, the first thing you’re encouraged to do is make an appointment with your doctor. If you can, getting a medical professional in your corner to provide a definitive diagnosis, effective coping strategies and tools, and to offer you mental health resources can be a helpful first step. And if you’re hearing voices, seeing things when you’re not sure if they’re there, or are thinking about harming yourself or your baby, it’s urgent that you seek medical care right away.
For most perinatal and postpartum mental illnesses, research also suggests other specific items that can help you manage your mental health, although they won’t replace the support of a licensed professional. And, of course, when you’re struggling to care for a baby, sometimes doing even one more thing may seem impossible. You deserve care and support, and perhaps even one of these items can help you get a little air so you can get the additional care you need.
I cringe as I write this because while most new parents are desperate for sleep, they would be sleeping if it was easy to come by. Yes, every new parent wants to sleep, and almost every new parent is struggling to do so. One of the biggest contributing factors to postpartum mental health struggles (and, frankly, mental health challenges in general) is lack of sleep, so whatever you can do to get some additional rest will be beneficial. Many providers encourage new parents to sleep when their babies sleep, and if that works for you, then by all means, do it. When I was feeling most anxious, I found that I was unable to sleep due to fear of what could happen to the baby, even when I was exhausted. The only time I could sleep soundly was when another trusted adult was monitoring the baby (and awake), so I could finally let down my guard. If you’re similarly struggling, a way to access more rest could mean enlisting the support of your partner, family, or friends; anyone you trust to look after your baby for a few hours so you can obtain the sleep you need.
We have all heard the saying that it takes a village, but in the US, a village is often not in the plans. New parents work to navigate so many broken systems, and there is very little if any, parental support. We expect ourselves to do it all, and we want to do our best for our children. The truth is that it’s nearly impossible to do this alone. And for those that are doing it alone, the cost might be their mental health. Research backs that a lack of social support is a risk factor for postpartum mental health challenges and that additional social support may serve as a protective factor. Mental health difficulties can make it hard to reach out to others, even when there are people to reach out to, and of course, many new parents may be isolated for a variety of reasons and may not be able to access support easily. If possible, consider the available resources and how to use them.
Many hospitals offer free support groups for new mothers, and for many, meeting with others experiencing the same challenges on a weekly basis can offer a lifeline. There are also parent and me groups facilitated by licensed mental health professionals that can allow for play and, more importantly, for much-needed connection and understanding. If you are fortunate enough to have friends or family nearby whom you trust and who are eager to help, it can be valuable to be explicit about what you need instead of trying to take everything on yourself. Don’t ignore the “let me know if you need anything” messages. Instead, tell them what you need. Do you need someone to sit with you for a couple of hours? Or to watch the baby so you can nap or shower? Do you need someone to bring over a meal? Often, the people who love you are eager to do something and will welcome some direction so they can be of service. Finally, there are many excellent online resources, including free online support groups through postpartum support international. No one benefits from your suffering alone.
It’s also vital that you try to treat yourself with kindness at this time. When expecting a baby, you will receive different messages about how you “should” or “shouldn’t” behave to do what’s best for the baby. We receive so many messages, from what to eat or to avoid eating to how we should plan on delivering the baby and what we should plan on feeding the baby. I remember actually worrying about whether putting my child in a stroller was less loving than having them in a carrier, even though my back was in excruciating pain, because I wanted to be mindful of our attachment (and was having trouble thinking for myself). And of course, we receive so many harmful messages about how are supposed to look postpartum. We forget that we also matter and are doing our best. Instead of affirming our efforts and offering ourselves understanding, we are often led to believe that every choice we make is wrong. It is critical to care for yourself and to have compassion for yourself. Sometimes, factors outside your control change what is possible for you, and it’s okay to make choices that prioritize your well-being. Parents struggling with their mental health often invalidate and minimize their own experiences and feel guilty when what we need most is compassion. You matter and deserve care.
Move Your Body:
Research supports that exercise can reduce depressive symptoms. While it certainly won’t eliminate the mental health struggles associated with peripartum and postpartum challenges, it could help make them a bit more manageable. Start small, find what seems most doable, and do that. You could play a three-minute song and dance with (or near) your baby. Or maybe a walk up the street and back is what’s most manageable. There are also yoga classes for expecting parents and parents with babies, if that’s your speed. I would encourage you to honor yourself and acknowledge what you can do right now instead of pushing yourself to do something that might feel out of reach or could exacerbate your anxiety and sadness. Any one of these could be a way of taking care of yourself, which is what counts.
So much more could go into this article, and so much goes into parenting that can be beautiful and incredibly painful. It’s okay not to have all the answers; if you’re feeling lost or overwhelmed, you’re not alone. While we’re making strides in recognizing the pregnancy and postpartum mental health challenges, we are just getting started, and many have silently battled them for ages, worldwide. We hope that, sooner rather than later, accessing the support we need becomes second nature for new parents. If you find yourself in need of any help, we’re here for you, ready to be a part of your journey in whatever way we can. Don’t hesitate to reach out – you don’t have to do it alone.