Text adapted from: "Perinatal mood and anxiety disorders," in Psychiatry in primary care by Ariel K. Dalfen (CAMH, 2019).
Recognizing Common Perinatal Psychiatric Disorders
“Baby blues” is not considered a psychiatric diagnosis, but an adjustment experience that 50 to 90 per cent of new mothers go through. Symptoms begin within the first few days after childbirth and include feeling overwhelmed, anxious and tearful, and having insomnia. Symptoms typically resolve after two weeks postpartum. No major psychiatric intervention is required, but psychoeducation about how common baby blues is, as well as advice around improving sleep and increasing social supports, can help. If symptoms persist well beyond two weeks and significantly affect functioning, further psychiatric evaluation is required.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) features a new peripartum onset specifier for major depressive disorder: the mood symptoms occur during pregnancy or within four weeks of delivery. Many experts agree that postpartum illness may begin up to one year postpartum.
Depression During Pregnancy
The symptoms of depression during pregnancy may be similar to those in non-perinatal depression. Women with perinatal depression often experience significant feelings of worthlessness and guilt about having psychiatric symptoms at this time. They may have limited interest in being pregnant and preparing for the baby’s arrival. In severe cases, this may result in poor self-care, weight loss or substance use problems. Physical symptoms of depression, such as disruptions to sleep and appetite, are less reliable indicators during pregnancy.
Postpartum depression may present similarly to non-perinatal depression. Again, the clinical picture often includes significant guilt and feelings of inadequacy and worthlessness as a new mother. High anxiety around decision making and baby care is very common. Significant insomnia is a sensitive marker of postpartum depression, as is significant anxiety. Women may have fantasies about escaping from their new role. In more severe cases, they may have suicidal or homicidal ideation, which must be evaluated and addressed immediately.
Postpartum psychosis is a psychiatric emergency. It is a rare disorder that affects 1–2/1,000 new mothers. It usually begins within one to three weeks after delivery. Early signs include insomnia, mood lability and significant agitation. The patient may then appear cognitively impaired, that is, disoriented to time and place, and may also develop delusions and hallucinations. The patient may develop suicidal or infanticidal ideation, or may respond to command hallucinations to harm herself or the baby.
Risk factors for postpartum psychosis include a history of bipolar disorder and postpartum psychosis. The recurrence rate of postpartum psychosis is 70 to 90 per cent in subsequent pregnancies. Patients usually require hospitalization, and treatment often involves antipsychotic and/or mood stabilizer medications. ECT may also be used if the condition is particularly severe or does not respond to medication.
Learn more about psychosis.
Anxiety is very common in the perinatal period and affects about 13 percent of pregnant women and new mothers.
Generalized Anxiety Disorder
Signs of generalized anxiety disorder include excessive, uncontrollable worries about common, everyday issues, such as the baby’s sleep or health, or about finances and work. The level of anxiety is high enough that it consumes a significant amount of time and affects functioning at work, home and in relationships. The anxiety is accompanied by physical symptoms, such as insomnia and muscle tension.
Panic disorder is characterized by panic attacks, fearing the recurrence of panic attacks and avoiding situations where the person fears having an attack. New mothers may avoid being alone with their baby for fear of having a panic attack. The avoidance behaviours may significantly affect other family members because the mother may seek never to be alone. New mothers with panic disorder may frequently present to the emergency room with somatic concerns, such as a racing heart or chest pain.
Obsessive-compulsive disorder (OCD) can occur at higher rates during pregnancy or postpartum, and pre-existing OCD can worsen. Symptoms include intrusive, often violent thoughts about harming the baby, or sexual thoughts. Although these thoughts are highly distressing in postpartum OCD, they are not associated with actually harming the baby. Explain this fact to women who have these symptoms because it is helpful for them to hear that the high anxiety they feel about the intrusive thoughts indicates that they know the difference between right and wrong and thus will not actually harm the baby.
It is important to differentiate these symptoms from psychotic delusions of infanticide, where a mother will not experience high distress and there is high risk to the baby’s safety. Women with perinatal OCD often experience significant shame and feel that they are “bad” or “unfit” mothers, so education and reassurance, along with treatment, are important.
Posttraumatic Stress Disorder
Posttraumatic stress disorder (PTSD) is no longer considered an anxiety disorder in the DSM-5, but it is common among perinatal women. Traumatic events may occur during pregnancy, labour or delivery. Trauma before this period can be re-experienced in pregnancy or as a new mother. Women with PTSD often have distressing flashbacks or nightmares and high anxiety. They may avoid certain medical procedures, such as vaginal examinations, or they may fear vaginal delivery, or even avoid caring for the baby if the baby is associated with the trauma.
You may not need to be aware of the details of a woman’s traumatic experience, but you must be aware that a traumatic event has occurred, provide support and show sensitivity to her experience.