With the heightened media exposure of postpartum mood disorders we are finding an increase of people seeking therapy for such issues. Perinatal is a term often used to describe the stage between conception to one year postpartum. Many individuals or couples seek help during this time because pregnancy, birth and parenting are life-altering events. It is important for the therapist, as well as the parent(s) to recognize this and to realize that there is no way to have life resume as “normal” once these events have occurred.

New parents are dealing with changes in identity, learning to adjust to the role of parent, heightened or newly discovered problems in the couple relationship, and financial, career or housing issues add to the stress they face. In fact the most common time postpartum mood disorders present themselves is two to three weeks after the birth of a child, which coincides with the end of initial post-birth support of friends and family. This is also a time when fathers will typically go back to work. Social isolation, problems in couple relationship, history of depression, low socioeconomic status, lower education, and age (below 20 or above 40 years old), as well as hormone imbalances are among the list of factors which may increase a person’s likelihood of developing a postpartum mood disorder.

Postpartum mental health problems include anything from the baby blues, depression, anxiety, OCD, bipolar disorder, psychosis and PTSD. Many of these issues were presented during the luncheon. First, it is important to recognize the difference between “the blues” and postpartum depression. The onset of the blues typically occurs one week after birth and 80% of women experience this. The symptoms last for up to three weeks and they present as weepiness, sadness, concerns around being a good parent or how to care for the baby, lack of concentration and feelings of dependency. In contrast, postpartum depression occurs in 15-20% of women. The onset is more gradual and can occur until one year after birth, and the symptoms are irritability, feeling overwhelmed, loss of focus or concentration, hopelessness, anhedonia, discomfort around the baby, lack of self-care, and suicidality (this could present as believing someone could do a better job raising the baby).

Anxiety is one of the most common present problems during the postpartum period, but that does not mean that it is normal. Anxiety can lead to hypervigilance around the baby. Because depression and anxiety go hand-in-hand, here are some good assessment questions to ask:

• What is your sleep pattern? How often do you awaken? Do you awaken refreshed?
• When was the last time you ate? What have you been eating?
• Tell me about your response to learning that you were pregnant?
• What is your experience of parenting?
• Is this your first pregnancy? Birth? Baby? Experience with breastfeeding?
• Have you ever had an experience with a mood disorder in the past?
• Tell me about your couple relationship.
• Are you experiencing a difference in your thought patterns? Are your thoughts critical? Racing? Frustrated? Angry? Frightening?
• Are you having thoughts of hurting yourself?
• What are your thoughts about returning to work or school?

With the last one in particular look for feelings of guilt they may be experiencing.

Postpartum manifestation of obsessive-compulsive disorder is unique. It is important to ask about frightening thoughts or fantasies that the client knows are irrational, especially if those thoughts are disruptive to the client’s day. These thoughts can be anything from accidentally drowning the baby while bathing it, having accidents involving the baby, the baby falling, or other situations that the mother avoids. It can also involve “waking nightmares”. OCD may lead to further isolation and shame. Some assessment questions to assess for OCD are:

• Do you ever have frightening thoughts concerning the baby or someone you care about?
• Are the thoughts disruptive to your day or to the choices you make?
• What happens when you have these thoughts?

The difference between OCD and postpartum psychosis is that people experiencing OCD are more aware that those thoughts are wrong.

Postpartum psychosis is relatively rare, occurring in only 1 or 2 per thousand mothers. However, almost every woman thinks she has it, and many are hesitant to seek help. They may fear the stigma of being a bad mother, or perhaps they fear that their child(ren) will be taken away from them. Postpartum psychosis presents with visual, auditory and/or olfactory hallucinations and delusional thinking. The content is often religious in nature (for example, Andrea Yates believing her children were possessed by the devil and she had to rid the world of them). They do not realize it is abnormal; it is very hard for them to determine what a reasonable fear is and what it is not. Postpartum psychosis is a crisis that requires hospitalization. The baby, mom, or other family members are in danger. This will require a multi-modal care team to treat.

Research indicates that bipolar disorder that was sub-clinical before birth is often the cause of postpartum mood disorders. It is important to assess for previous mania and a family history of bipolar disorder. Some questions that can be asked are:

• Is there a history of mood disorders in your family?
• How would you describe your mood after the birth of the baby?
• What has your sleep pattern been like since the baby’s birth? Can you sleep when the baby is asleep?
• Have you ever seen or been aware of something that no one else can perceive?

One should be aware that sleep deprivation may lead to psychosis, and should be ruled out. Also, a client with bipolar disorder will generally seek help in a depressive stage, so be sure to assess for manic episodes.

People may experience post traumatic stress disorder due to the birth of their child. It could be something traumatic about the birth itself, or something resulting from their childhood, whether consciously remembered or not. If epidurals were used during the birth, the body is generally numb and the woman will be aware that something is happening around her lower extremities but will be unable to do anything about it. If she has been sexually abused, she may dissociate, which in turn may scare her and/or her partner. Men may also experience trauma because they are unable to fix whatever is happening or the pain their partner is experiencing. Hospital workers, caretakers, the father, or other family members may experience secondary trauma when the mother is unaffected. Ask questions about the history of conceptions, pregnancies and births:

• What were your expectations of birth during pregnancy?
• Were there any complications during pregnancy/birth?
• Is there a history of trauma?
• How did being a part of pregnancy and birth affect your partner?
• Are there any mixed feelings?

As addressed in the above paragraph, fathers also experience perinatal-onset mood disorders and traumas. Paternal problems occur at approximately half the rate they occur in mothers, though these problems may be underreported. Additionally, maternal disorder increases the likelihood of the father having a disorder. As practitioners, we most likely will not see men present themselves, but when counseling couples you will see it. Many times the problems will present as the father indicating difficulty attaching to the baby. Ask the father about his experience of fatherhood and the birthing process.

While assessing for postpartum mood disorders, follow your normal procedure paying particular attention to ways disorders may manifest during this unique time. Look for a history of substance use, suicidality, cutting behavior, or eating disorders, as those issues tend to manifest again after the birth of a child. Remember that birth is a sexual event; so pay particular attention to trauma concerns. Other assessment tools to use to specifically screen for postpartum mood disorders are the following:

• Postpartum Depression Screening Scale
• Edinburgh Postnatal Depression Inventory
• Center for Epidemiologic Studies — Depression Scale
• The Burns Anxiety Inventory

Suicide is one of the top three leading causes of death during the postpartum period, therefore the most important intervention is safety planning. Continually reassess the risk, check on family support, medical support, and educate the client and partner. Have suicide and crisis numbers available at all times. Group therapy decreases isolation, decreases the “myths of motherhood,” and will put the individual/couple in touch with local resources. Therapy may help the couple realize they cannot ever get back to “normal,” but they will redefine what “normal” means with a child, facilitating reconnection and communication. Individual therapy can help define what a “good mother” is, teach adjustment/mood stabilizing techniques and address and encourage self-care. For those who have experienced trauma it will be important to address it in therapy. Medication can be left up to the individual whether they want it or do not, as few studies have proven its efficacy.

For more information on postpartum mood disorders please refer to the following organizations:

• Postpartum Support International
• North American Society for Psychosocial Obstetrics and Gynecology
• Coalition for Improving Maternity Services
• Association of Pre- and Perinatal Psychology and Health
• Trauma and Birth Stress

Presented by: Angie Nunes, MFT, and Sharon Storton, MFT

Reviewed by: Amy Sargent