When to seek care for maternal and postpartum mental health concerns

Pregnancy and having a baby can be one of the most joyful times in your life, but they also represent an enormous spiritual, emotional and physical transition. Recent national conversations surrounding severe postpartum mental illness only highlight how important it is to understand that postpartum depression, postpartum anxiety and postpartum psychosis aren’t the same thing, and they are very real problems that can come up during pregnancy as well as after the baby is born.

OB/GYN Matthew Scalise, MD, has treated patients struggling with postpartum mental illness. He spoke with us on how mental health can change during pregnancy and after delivery, what symptoms of postpartum mental illness to watch out for and why it’s essential to take these concerns seriously.

What causes your mental health to change during pregnancy and postpartum?

“There really isn’t one single cause,” said Dr. Scalise. “During pregnancy, the body undergoes major changes in hormones, sleep, metabolism and overall physical health. After delivery, estrogen and progesterone levels fall rapidly while the mother is still recovering physically from childbirth.”

Mothers rarely get more than short intervals of sleep during those early postpartum days. They may be breastfeeding around the clock, struggling with sleep deprivation and being asked to adjust rapidly to a change in their identity.

Add in a difficult pregnancy or delivery, having a baby in the NICU, lack of support, financial or relationship stress, previous trauma and pregnancy loss, and the strain a postpartum mom’s body and mind are under can be truly enormous. Further, anxiety and depression that existed before pregnancy may become better, worse or simply different during pregnancy or after delivery.

What’s the difference between postpartum depression and postpartum anxiety?

“There is quite a bit of overlap, and some women experience both,” said Dr. Scalise. “In postpartum depression, the dominant symptoms tend to be persistent sadness, hopelessness, loss of enjoyment, guilt, low motivation or feeling disconnected from yourself or your baby. There may also be significant changes in appetite, sleep, energy and concentration. In more severe cases, a person may feel worthless or have thoughts of death or suicide.”

In postpartum anxiety, worry and fear tend to dominate. Many women say they can’t “turn off their brain.” Moms with postpartum anxiety may constantly worry that something bad will happen to the baby, repeatedly check that their infant is breathing, have racing thoughts, experience panic attacks or feel a persistent sense of dread even when everything appears to be going well.

Physical symptoms of postpartum anxiety tend to include a racing heart, nausea, dizziness and difficulty sleeping.

What is postpartum psychosis?

“Postpartum psychosis is very different from postpartum depression or anxiety,” said Dr. Scalise. “It is also rare, occurring in roughly 1 to 3 out of every 1,000 births.”

Postpartum psychosis often develops suddenly after childbirth and can include symptoms such as:

• Hallucinations
• Delusions
• Extreme paranoia
• Confusion
• Disorganized behavior
• Severe insomnia
• Symptoms of mania such as unusually elevated energy, racing thoughts or very little need for sleep

Someone suffering with postpartum psychosis may say or believe things that are clearly inconsistent with reality but be unable to recognize that those beliefs are false. Bipolar disorder is an important risk factor.

“Postpartum psychosis is a medical emergency,” Dr. Scalise emphasized. “The judgment and ability to gauge reality of someone with postpartum psychosis may be severely impaired. They may become dangerous to themselves, their baby or others around them. Postpartum psychosis typically requires immediate psychiatric evaluation and often hospitalization.”

What can you do if you take medication for already existing mental health conditions and become pregnant? Do you have to stop taking your medication?

“Pregnancy does not automatically mean stopping psychiatric medication,” said Dr. Scalise. “Current guidance from the American College of Obstetricians and Gynecologists (ACOG) recommends against stopping mental health medications simply because someone is pregnant or breastfeeding.”

Abruptly stopping medication that has kept someone stable can sometimes be more dangerous than continuing it. Untreated depression, anxiety or bipolar disorder can also affect the health of the mother, the pregnancy and the postpartum period.

Instead, it’s important that the patient and her medical team review the specific medication, dose, diagnosis, how severe the condition has been in the past and what happened during previous attempts to stop medication. Some medications have considerably more pregnancy safety data than others, and sometimes a medication or dose may need to be changed.

How are mental health concerns diagnosed and treated during pregnancy and postpartum?

“Maternal mental health should be assessed continuously throughout pregnancy and after childbirth,” said Dr. Scalise. “Too often new moms can feel like they’re totally alone until that traditional six-week postpartum visit. ACOG recommends screening for depression and anxiety at the initial prenatal visit, later during pregnancy and during postpartum care using validated screening tools.”

Treatment depends on the condition and its severity. For depression and anxiety, treatment may include counseling, improving sleep quality, addressing stressful circumstances and medications such as antidepressants when appropriate. Many patients benefit from both therapy and medication.

It’s very important to know that care does not stop after delivery. Medication may be continued or adjusted, breastfeeding considerations can be discussed and you should continue to be screened during postpartum visits. Psychiatry, psychology, counseling and other community resources may be added when needed.

Severe depression, suicidal thoughts, mania or psychosis require a much more urgent level of evaluation. Postpartum psychosis should not be managed by simply waiting for an outpatient appointment.

Will PPA or PPD go away on its own at some point after the postpartum period ends? Does it always require treatment?

“One of the most common sources of confusion is the difference between the ‘baby blues’ and postpartum depression,” said Dr. Scalise. “The ‘baby blues’ are extremely common. A new mother may cry easily, feel overwhelmed, be irritable or experience rapidly changing emotions during the first days after birth. These symptoms usually improve within several days to about two weeks without specific medical treatment.”

Postpartum depression and anxiety are different. These conditions can last many months and sometimes longer without appropriate treatment. To be clear, not every person with mild anxiety or a difficult emotional week needs medication. Sometimes basic supportive measures such as additional sleep and counseling can make a significant difference.

The goal should not be to see how long someone can tolerate feeling miserable before asking for help. There is no prize for suffering through postpartum depression or anxiety alone.

What are some signs or symptoms during pregnancy or after giving birth that might mean you should speak to your doctor?

“I want to really emphasize that you don’t have to wait until symptoms are severe before seeking help,” said Dr. Scalise. “Persistent sadness or hopelessness, losing interest in things you normally enjoy, constant or uncontrollable worry, panic attacks, overwhelming guilt, unusual anger or irritability, difficulty bonding with your baby, significant changes in appetite, inability to sleep even when you have an opportunity to sleep or feeling unable to take care of yourself or your baby are all reasons to reach out!”

Other symptoms that should be considered emergencies are hallucinations, delusional beliefs, severe confusion, extreme paranoia, bizarre or markedly disorganized behavior, symptoms of mania, thoughts of suicide or thoughts of harming another person. All of these require immediate evaluation.

Mental health care is part of pregnancy care

“Expecting and postpartum moms should feel just as comfortable bringing up severe anxiety, depression or unusual thoughts as they would bleeding, contractions or high blood pressure,” said Dr. Scalise.

If you are pregnant or postpartum and need support, the National Maternal Mental Health Hotline is available 24 hours a day by calling or texting 1-833-TLC-MAMA (1-833-852-6262). If you are experiencing a mental health crisis or having thoughts of suicide, call or text 988.

Hallucinations, delusions, severe confusion, postpartum psychosis or an immediate risk of harm to yourself or someone else warrant emergency medical care or calling 911.