Pregnancy and childbirth are often thought of as times of joy, yet mental health issues can complicate this experience. One of the most famous modern cases centered around a Houston woman named Andrea Yates, who a judge convicted of murder in 2002 after she drowned her five children. Yates was later found not guilty by reason of insanity. She was also diagnosed with postpartum psychosis. The 2023 news story of Lindsay Clancy is another example of the devastating consequences of pregnancy-related mental health disturbances. Lindsay was a normal mom regularly sharing photos of herself happily smiling and hugging her three kids. Yet Clancy was charged with murdering her children before attempting to take her own life. It is difficult to comprehend what led to this mother to lose her grip on reality and harm her children. At her trial, Clancy’s legal defense emphasized that since her youngest child was still a baby, this mother may have been suffering from undiagnosed postpartum psychosis. When reviewing this case in hindsight, it is clear that appropriate intervention may have prevented tragedy. This lawsuit has sparked a nationwide conversation regarding the importance of post-partum mental health education.

The first step in educating ourselves is clarifying language and terminology. Post-partum depression/psychosis is not a reference to the ‘baby-blues,’ but in a wide variety of serious mental health disturbances. A mild degree of post-partum depression is considered common. A new mother meeting criteria is tearfulness and irritability, isolating and hopelessness. This temporary state usually resolves in a few weeks. However, 25% of women can experience anxiety, depression, obsessive compulsive disorder (OCD,) post-traumatic stress disorder ( PTSD,) bipolar disorder (BPD) and psychosis at any time during pregnancy up to a year after birth. Recent research has found that Perinatal Mood and Anxiety Disorder (PMADS) diagnoses increased by 93.3 percent between 2008 to 2020 nationwide among the privately insured. In the United States, 25% of maternal mortality is due to mental health issues with suicide as the leading cause of death. In Kentucky from 2017 to 2020, 13.9% of mothers experienced PMADS. Unfortunately, 75% of women do not receive treatment often due to a lack of awareness and education about these issues. To further compound the problem, an idealized expectation of the motherhood experience complicates the issue by creating shame that keeps new moms from asking for help.

Several factors can contribute to the risk for PMADS, including hormonal changes, a history of mental health issues, lack of social support and stressful life events. Challenges related to the pregnancy such as a long period of morning sickness or labor, traumatic childbirth experience, complicated anesthesia, past medical trauma and neglectful medical staff may increase risk of PMADS. Adverse childhood experiences (ACES) such as physical/ sexual abuse or assault can be a risk factor for PMADS through biological embedding. This process occurs when elevated stress levels during or following gestation alter the nervous, endocrine and immune system’s functioning. Biological embedding can activate the body's stress-processing systems which can manifest in a depressive disorder when hormone levels change dramatically during pregnancy and lactation. Biological processes such as thyroid disease, a history of premenstrual dysphoric disorder or lack of restorative sleep can also put a new mom at risk. Finally life and role changes, such as being a first-time mom, feeling isolated without help and financial instability are situations that put women in jeopardy. Women who have unrealistic expectations, anxious/sensitive personalities and perfectionistic tendencies can be precursors to PMADS.

Just as imperative to educating a mother-to-be, it is also vital that family are able to recognize signs that mom may need intervention and/or how to reduce the risk for PMADS. Of particular interest, a new mother’s partner should be aware of the signs and symptoms of PMADS to prevent tragic death. Helping with the new baby, other children and maintaining the home to relieve stress on a new mom is key to keep her from being overwhelmed. Emotional strain can trigger depressive symptoms in the father. Paternal PPD is often overlooked because of the traditional view that men should not express vulnerability. New dads are reluctant to seek help as they do not feel their emotions are valid in comparison to the mother’s experience, which is typically seen as more physically and emotionally taxing.

PMADS is not a monolithic experience, but rather can manifest along a spectrum of disturbances. The following is an overview of the different types of PMADS:

1. Postpartum Depression (PPD)
Sadness, hopelessness, fatigue, loss of interest in daily activities, difficulty
bonding with baby and thoughts of harming self or baby
Onset during pregnancy or postpartum

2. Postpartum Anxiety/Panic (PPA)
Excessive worry and rumination, panic attacks, restlessness, tenseness,
intrusive thoughts and unwarranted fears for baby’s health or safety
Onset during pregnancy or postpartum

3. Postpartum Obsessive-Compulsive Disorder (PPOCD)
Obsessive, intrusive thoughts (harming baby,) compulsive behaviors to
prevent harm, excessive cleaning and guilt/shame of irrational thoughts
Onset early postpartum period

4. Postpartum Post-Traumatic Stress Disorder (PTSD)
Flashbacks, nightmares, avoidance of childbirth trauma reminders
(places/people,) hypervigilance and irritability
Onset relates to traumatic birth experience, medical complications or
emergency interventions

5. Postpartum Bipolar Disorder
Mood swings between mania and depression, impulsiveness, racing
thoughts and need for decreased sleep during mania
Onset during pregnancy or postpartum, especially if the mom has a
personal or family history of bipolar disorder

6. Postpartum Psychosis
    Hallucinations, delusions, paranoia, confusion, agitation, irrational
thoughts or harming self or baby
    Onset within first two weeks postpartum. Rare but serious with 5%
suicide or infanticide
    Risk factors: First baby, unmedicated bipolar triggered by pregnancy is
double the risk, sleep deprivation, references to God commonly involved
    Requires hospitalization, medication and therapy

Recognizing PMADS is an important first step, but help and hope are available to mitigate severe consequences. Each person’s treatment will be unique according to their experience. Best practices recommend a thorough medical examination to include a psychiatric evaluation. Therapy can be a varied approach with cognitive behavior therapy, mindfulness-based CBT, interpersonal therapy, attachment based/parenting therapy and support groups. Patients should be treated with understanding and support due to the shame they feel because society expects them to be happy, not sad.

Common comments from PMADS clients include, “I must be the worst mother in the world,” “I am having thoughts that are scaring me,” and “I am worrying all the time.” Themes of therapy include realistic expectations for parenthood, reducing perfectionism and comparison to others, anger management, grief and loss and establishing connective support. If medications are necessary, GeneSight testing, to analyze how a person’s genes affect their response to certain medications, may be helpful. Anti-depressants, Brexanolone (IV) or Zuranolone (oral) are FDA approved for post-partum depression. In some severe cases, hospitalization is necessary.

What needs to be done? Increased education on PMADs during obstetrician visits to help mothers understand their symptoms and to eradicate an impression of failure. Women should be screened for early intervention. Not only at the OB office, but at pediatric visits where the focus is usually on their new baby (not the mom) and in mental health practices. In fact, a collaborative, multidisciplinary team of specially trained medical/mental health clinicians should support mothers through each pregnancy and postpartum year. There is a great need for psychiatrists to be trained in reproductive psychiatry to help patients. During a psychologically vulnerable time of physiological, hormonal and identity change, peer support groups help to mitigate development of PMADS. Policy changes for paid family medical leave and access to quality childcare can help to reduce PMADS by softening parental stressors.

If you think you or a loved one may be experiencing a PMAD, Postpartum Support International (PSI) has a helpline available at 1-800-944-4773 (4PPD). PSI also has free online support groups and a directory where you can find providers to work with individually in your area. The National Maternal Mental Health Hotline is available 24/7 at 1-833-852-6262

Suzette Turner-Clark, LCSW-S, RPT/S, RYT-200