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Perinatal and Postpartum Depression: What to Know as a Mother-to-Be

Editor's Update: This article was first published March 14, 2018. It was most recently reviewed and updated April 21, 2020.

Fill in the blank: The ____ of motherhood.

The word that comes to mind is probably “joy.” But creating and caring for a new life is complex — physically and mentally. A pregnant woman has more hormones surging through her body than at any other time — including 15 to 40 times more progesterone and estrogen. The physical changes during and after pregnancy can also drive emotional changes. And let’s not forget that this is a time when a woman faces countless new choices and responsibilities that are, quite literally, life-changing.

Samantha Ferris

Samantha Ferris, CRNP, is board certified as an Adult Psychiatric Mental Health Nurse Practitioner, has over 10 years’ experience in mental health, and has a special interest in women’s health and perinatal mood disorders.

Even in the best scenarios, all that change can make mental health support as important to the childbirth journey as prenatal classes, healthy lifestyle choices, and baby’s first pediatric checkups. Allegheny Health Network (AHN) offers a comprehensive program of pregnancy-related depression and anxiety services to make sure women get that support. To learn more about what moms-to-be should know about mental health, I spoke with Samantha Ferris, CRNP, part of the AHN team helping women and their partners get the information and resources to ensure the happiest, healthiest experience for mother and child.

The “Perfection” of Motherhood

Society often portrays an image of motherhood that is too perfect to be possible. Feeling anything less than pure joy while pregnant or after giving birth does not mean you do not love your baby. Trying to cover up feelings that fall short of “pure joy” is stressful and unhealthy, and can also cause women to avoid seeking mental health support or to miss signs that support is needed.

In fact, only 15 percent of women with perinatal mood and anxiety disorders like postpartum depression receive professional treatment. Ferris says that a common obstacle is that a woman feels guilty for being depressed or anxious at all:

New mothers say to themselves, ‘This is supposed to be the happiest time of my life. I have everything I could want. I have this beautiful baby, my family is all around me, but I just cannot get excited about it.' They feel guilty and ashamed, and that’s why many women delay getting treatment, or worse, don’t seek treatment at all.

It’s important, and healthy, to say goodbye to any guilt or shame at not always feeling happy. Studies estimate that 25 percent of Americans have anxiety, depression, or another mental illness at any given time, and 50 percent will have at least one mental illness during their life. Having a baby doesn’t make anyone immune to mental illness; on the contrary, Ferris points out that the hormone surge during pregnancy, and hormone drop after giving birth, can have a profound impact:

The hormones associated with pregnancy interface with neurotransmitters that affect mood, which is why some women notice changes during pregnancy. Others don’t have many changes until that sudden drop in hormones after they deliver. One factor with postpartum depression is that, after birth, those hormones that were skyrocketing take a big dip, generally only returning to baseline levels over several months. The first few weeks after birth are usually the hardest — that’s the biggest rollercoaster, and it can have a huge impact on mood.

Perinatal and Postpartum Depression: Know the Signs

Feeling your feelings, and acknowledging that they are real, is healthy. But if you or someone you love is pregnant or has just given birth, how do you tell the difference between “normal” tiredness or mood swings associated with pregnancy and new motherhood, and something that might be a more serious problem?

First — when in doubt, get it checked out. Whether it’s your OB-GYN or family doctor, a program like AHN’s, a psychologist or another trained medical expert, prompt professional attention is the best way to protect the health of you and your baby. On the website, you can also find this helpful list of perinatal and postpartum depression symptoms:

  • Inability to experience pleasure
  • Feeling sad or empty the majority of the time
  • Feeling anxious (perinatal anxiety) or overly worried
  • Feeling irritable or on edge
  • Struggling to feel connected with your baby
  • Isolating yourself from family or friends
  • A change in appetite
  • Trouble sleeping or sleeping too much

Ferris adds that many OB-GYN doctors now screen for mental health problems at specific intervals during and after pregnancy. A standard tool is the Edinburgh Postnatal Depression Scale (EPDS) — 10 basic questions with a range of answers. Adding up the points associated with each answer provides a score to gauge whether you are experiencing normal mood swings or need further assessment and treatment.

The “Village” of Motherhood

A young mother, baby, and spouse surrounded by three medical professionals

Universally, across the entire AHN network, the approach to screening and treating mental health during pregnancy and after childbirth goes above and beyond. For example, all AHN OB-GYN practices now use both the EPDS and the Mood Disorder Questionnaire (MDQ) to screen women for depression and bipolar disorder. Screenings occur twice during pregnancy and once after birth. If results suggest that a woman is suffering from depression, anxiety or other mood disorders, the information goes immediately to AHN psychiatry clinicians for a closer assessment and triage to therapy if needed.

“That’s a really wonderful thing we have here,” Ferris says. “Not only are women getting screened, but they’re being given resources immediately for what to do if they are screened positive.”

Ferris adds that, even with good proactive screening and professional care, it’s also crucial for a woman’s partner, family and friends to stay vigilant. Often, they are the first line of defense in situations when depression and anxiety arise. She says that, for partners especially, it’s not just a question of paying attention to changes, but also overcoming the fear of speaking up.

“They see that their pregnant partner is already very sensitive and that her hormones are raging, so they may be worried about offending her by saying, ‘You don’t seem like yourself,' or suggesting getting help,” she explains. “But that’s a really important perspective to have, because the partner sees her every day, and knows what’s normal and what’s not. A partner is usually the first person to notice that something is wrong.”

In particular, Ferris says that, after birth, a partner should be concerned if the new mother is “not getting past that emotional rollercoaster in the first couple days, if she remains very easily tearful and is feeling overwhelmed with emotions. Often, there are sleep and appetite disturbances, feeling irritable, snapping out when she doesn’t mean to, not feeling motivated and just not enjoying anything. Wanting to isolate or dreading when visitors come to see the baby — any of these can be warning signs.”

The Alexis Joy D’Achille Foundation

Although it is truly a network-wide effort, AHN’s comprehensive care for women with pregnancy-related mental health concerns has a physical home at the Alexis Joy D’Achille Center for Women’s Behavioral Health at West Penn Hospital in Pittsburgh. The center opened through a partnership between AHN and the Alexis Joy D’Achille Foundation — and the D’Achille family’s story has been a driving force behind AHN’s commitment to do everything possible to support the behavioral health of women throughout pregnancy and after childbirth.

Postpartum depression took Alexis’ life just a few weeks after she gave birth to a daughter. Her husband, Steven D’Achille, transformed that terrible tragedy into an inspiring mission to improve awareness of postpartum depression and expand access to treatment in his wife’s name.

“There are not many programs like this in the country that offer both intensive outpatient care and partial hospitalization as options for women who need more than standard outpatient treatment,” Ferris says. “If symptoms are severe and you need extra support, weekly visits to a therapist or medication may not be enough. Coming in three days a week for three-hour visits in the intensive outpatient program is really helpful to a lot of women.”

The partial hospitalization program is the next step up. “If symptoms are even more severe, we still want to prevent full hospitalization if possible, because that usually means separation from your baby,” she explains. “That is what makes our program really special. Depression and anxiety in the perinatal period can make mother-child bonding very difficult, but our approach is built around doing everything we can to foster and help develop that bond. Instead of full hospitalization, we have mother and baby here together all day surrounded by professional support.”

The Joy of Motherhood

A young African-American woman holding a newborn

“Your lifestyle has a lot to do with your mood,” she says. “In our program I always tell women that you can go to therapy, you can take medication — and those things will help a lot — but you must also try to stay on a consistent schedule. Waking up and going to bed at the same time every day, getting the right amount of sleep, eating well, taking time for self-care — all these things are extremely important within the whole picture of wellness.”

Medication is just one piece of the puzzle for some women, but Ferris says it is a piece that too many women toss aside.

“There are many misconceptions and much fear out there around women taking medication when trying to conceive or during pregnancy or breastfeeding,” she says. “There’s misinformation online, but even some providers aren’t up to date on all the research about which medications are pretty low-risk during pregnancy and breastfeeding.”

To take just one example, if a woman has been successfully managing depression with medication, but then stops, scales back, or unnecessarily switches medications while pregnant or breastfeeding, she may relapse into depression, with detrimental effects for both her and her child.

“The symptoms of depression can interfere with a mother’s ability to take care of the baby,” Ferris points out. “Women who have depression tend to stop breastfeeding a lot sooner than women who don’t have depression. So, there are real risks in not treating your symptoms.”

She emphasizes that she and her colleagues respect women who want to take a very cautious approach with medication, and will always work with someone to minimize or avoid medication if possible — it’s just a matter of making sure decisions come from the best evidence-based research and guidance, not misinformation and fear. She adds that there are two online resources she recommends for good, up-to-date information:

  • A service dedicated to providing evidence-based information to mothers, health care professionals, and the general public about medications and other exposures during pregnancy and while breastfeeding
  • LactMed: A database containing information on drugs and other chemicals to which breastfeeding mothers may be exposed

Reliable information is incredibly empowering for women across the entire childbirth journey, especially in areas like mental health. “If people could be more open about their birthing experiences, the stigma and fear around mental health issues and treatment would dissolve,” Ferris says. “We have a long way to go, but we are getting there.”

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