What you should know about Perinatal Mood and Anxiety Disorders (PMADs)
What are PMADs?
Perinatal Mood and Anxiety Disorders (or PMADs) covers the different mood and anxiety-related diagnoses that may show up at any point for someone during pregnancy, post-loss, and postpartum. Many people talk about postpartum depression, but the reality is that mental health can be impacted in a variety of different ways that don’t get talked about nearly as often.
Why is this topic so important?
Perinatal mental health disorders are the most common complication of childbearing in the United States. They affect parents of every culture, every age, every income bracket, and every race. More than 800,000 people a year in the U.S. are impacted by PMADs. That is 1 in 5 families that this touches.
When maternal mental health is left untreated, it can have serious consequences for the mother or birthing person, the baby, and the entire family system. Despite this, they are frequently missed by our healthcare system as folks are not universally screened, or if they are flagged, they are often inadequately treated or misdiagnosed.
The good news is that specialized support and some really great resources are available. Getting help can help prevent these complications, reduce risk, and support recovery. Acknowledging you are struggling is not a failure, but a sign of immense strength and resilience.
Understanding the Diagnoses
Below is a brief snapshot of each of the PMADs diagnoses. It is common for these conditions to be co-occurring, and they can present in a lot of different ways. They can also show up at any point in the perinatal time period (pregnancy, post-loss, and postpartum), which is why it’s so important to seek specialized perinatal care with your providers.
Perinatal and Postpartum Depression
You may be experiencing feelings of anger, irritability, rage, deep sadness, hopelessness, guilt, shame, a loss of interest or pleasure in things you once enjoyed, trouble concentrating, a lack of interest in or trouble bonding with the baby, changes in eating or sleeping habits, and possible thoughts of harming yourself or the baby. These symptoms can range from mild to severe.
Research shows that 1 in 5 parents experience depression during pregnancy and the first year postpartum. Those with pre-existing depression prior to or during pregnancy are more likely to also experience postpartum depression.
Perinatal and Postpartum Anxiety
You may experience excessive worry, fear, and nervousness, often over the health and safety of your baby. You may also experience restlessness, irritability, anger and/or rage, racing heartbeat, racing thoughts, inability to sleep, changes in appetite. Some may experience panic attacks, which can include shortness of breath, chest pain, dizziness, numbness and tingling, and a feeling of losing control.
Research shows that 1 in 5 parents experience anxiety during pregnancy and the first year postpartum, with the highest rates happening in early pregnancy (25.5%). Anxiety may be experienced independently, but it is often co-occurring with perinatal/postpartum depression or obsessive-compulsive disorder (OCD).
Perinatal Obsessive Compulsive Disorder (OCD)
You may experience repetitive, unwanted, intrusive thoughts (obsessions) as well as irrational, excessive urges to do certain actions (compulsions). With perinatal OCD, these obsessions and compulsions often center around the health and safety of the pregnancy and/or the baby. For some, the symptoms are severe enough to get in the way of every day functioning (like brushing your teeth, driving a car, or leaving the house).
Repetitive, intrusive thoughts and images can feel very frightening, and can seemingly “come out of the blue.” It is important to note that while these thoughts and images feel alarming, they do not represent a break from reality or a psychotic process (where mothers are at a higher risk of harming themselves or their children). Parents who are experiencing these symptoms will frequently take steps to avoid the triggers and what they fear could harm the baby.
The prevalence of OCD is about 8% during the prenatal period, and about 17% during postpartum.
Bipolar Disorders
Many people are diagnosed for the first time with bipolar disorder (either Bipolar I or Bipolar II) during pregnancy and postpartum. Bipolar disorder can often look like a severe depressive episode, or anxiety. You may experience symptoms such as severely depressed mood and irritability, elevated mood or higher energy than typical, rapid speech, little need for sleep, racing thoughts, trouble concentrating, impulsiveness and poor judgment, overconfidence, grandiose thoughts, distractability, and in severe cases, delusions and/or hallucinations.
Bipolar I disorder is characterized by at least one manic episode that may come before or after a hypomanic or major depressive episode
Bipolar II disorder is characterized by at least one major depressive episode and one hypomanic episode without any manic episodes
For women without a psychiatric condition before the perinatal period, the prevalence of Bipolar disorder is 2.6% and the prevalence of bipolar-spectrum mood episodes (depressed, hypomanic/manic, mixed episodes) is 20.1%. For women with an existing bipolar diagnosis, 54.9% have at least one bipolar-spectrum mood episode occurrence in the perinatal period.
Perinatal Post-Traumatic Stress Disorder (PTSD)
PTSD in the perinatal period is often caused by a traumatic or disappointing childbirth or past trauma. The trauma may be related to pregnancy complications, medical interventions during childbirth that caused physical or emotional harm, the baby going to the NICU, life-threatening situations for the mother or baby, feelings of powerlessness and/or lack of support and reassurance during the delivery process, severe physical complications or injury relating to pregnancy or childbirth. Up to 45% of women describe their childbirth experience as traumatic, although not all will go on to develop PTSD in response.
Symptoms may include flashbacks of the trauma with feelings of anxiety, the need to avoid reminders associated with the event (including thoughts, feelings, people, places, and details of the event), persistent increased arousal (irritability, difficulty sleeping, hypervigilance, exaggerated startle response), anxiety and panic attacks, feeling sense of unreality and detachment, avoidance of aftercare following a birth trauma.
Perinatal and Postpartum Psychosis
Perinatal psychosis, or postpartum psychosis (PPP), is a serious perinatal mental health disorder that usually has an onset in the first two weeks, but can be experienced up to a year postpartum. You may be experiencing the inability to sleep, seeing images or hearing voices that others cannot, believing things that are not true and distrusting those around you, feeling hyperactive or having more energy than usual, severe depression or lack of emotion, rapid mood swings. You may have periods of confusion, mania, depression, or memory loss.
Postpartum psychosis is rare, occurring in approximately 1 to 2 out of every 1,000 births. While it is uncommon, it is dangerous and it is important to seek professional help immediately as it represents a medical emergency. The majority of individuals who experience postpartum psychosis do not harm themselves or anyone else. However, there is increased risk of danger due to delusional thinking and irrational judgment.
If you suspect postpartum psychosis, call an emergency crisis hotline right away.
Call or text the National Maternal Mental Health Hotline at 833-852-6262 (1-833-TLC-Mama), available 24/7
Call or text the National Suicide Prevention Lifeline at 988
Visit your local emergency room, ideally one with a perinatal specialist / department
A Note About Intrusive Thoughts
Most new mothers (like 70-100%) experience “intrusive” thoughts during the perinatal period. These thoughts may include infant harm (dropping the baby, harming the baby). These thoughts are very distressing and are unwanted (this is also called “ego-dystonic”) and the person experiencing them will recognize them as inappropriate and concerning. This is totally normal, and does not mean you are a bad mom, or that you will act on any of these thoughts. The fact that they feel upsetting is actually why these thoughts alone are not a cause for alarm.
Intrusive thoughts are not considered a disorder. It is part of being human. The focus is more on the reaction to the thoughts. Mothers are at a higher risk of harming themselves or their children if and when those thoughts start to feel reasonable and “make sense”, rather than causing distress. When intrusive thoughts persist, continue to feel distressing, and become disabling, this is often tied to OCD.
What about the “Baby Blues”?
The “Baby Blues” are not listed above, as it is not considered a mental health disorder. This temporary condition is experienced by the vast majority of folks after giving birth, tied to a sudden shift in hormones. If you are experiencing the baby blues, you may feel sad, experience mood swings, and feel frequently tearful. The symptoms typically resolve within a few days, however if they persist beyond two weeks, it is likely the birthing person may be suffering from depression.
Why do so many new parents experience PMADs?
The transition to parenthood is one of the most profoundly transformational changes we go through in our entire lifespan (read more about this life transition through the lens of “matrescence” in my recent blog post here). It often feels hard, because it objectively IS hard.
However, whether or not someone develops a perinatal mood and anxiety disorder is rooted in a combination of biological, psychological, and social factors, such as a lack of support or a personal or family history of mental health issues.
Over the last decade, the mental health of mothers in the U.S. has worsened. According to the Policy Center for Maternal Mental Health, between 2016 and 2023, mothers reported a nearly 65% increase of “fair to poor mental health.” Many mothers still feel uncertain about seeking mental health support due to perceived social stigma.
Disparities in perinatal mental health
It is critical to talk about the present disparities in perinatal mental health in the U.S., and how that has a disproportionate impact on those who hold marginalized identities (people of color, rural communities, and those living in poverty especially).
Black and Latina mothers in the U.S. suffer from postpartum depression at twice the rate of their white mother counterparts (40% compared to 20%). Up to 30% of American Indian and Alaska Native mothers suffer from postpartum depression. Yet these groups are also significantly less likely to receive adequate screening, diagnosis, and treatment.
Those living in rural communities are also at increased risk for perinatal mental health challenges, and are 21% more likely to develop postpartum depression compared to women in urban communities. Those living in poverty suffer from postpartum depression at twice the rate of those not living in poverty.
With a greater number of women in the U.S. unable to make autonomous decisions about their own healthcare, rates of depression and anxiety are expected to continue rising significantly.
When you should reach out for support
First and foremost, you are deserving of care and support as you walk through this incredibly tender and often overwhelming time. You do not need to be in crisis to be worthy of support. As human beings, we are not meant to walk through this alone. You have taken a courageous step even reading this post and taking some time to learn more.
If you are feeling completely overwhelmed, isolated and alone in your experience, anxious, depressed, or just struggling to cope with the daily relentlessness of caregiving… I encourage you to get some extra support. It’s okay to ask for help. Yes, even you.
Support can look like joining a local support group, talking with your primary care provider (PCP), talking with your OB or midwife, seeking evaluation and treatment with a prescriber, and of course, mental health therapy.
Other supports may include lactation and feeding support, sleep specialists, postpartum doulas, couples counselors, acupuncturists… There is a whole community out here of specialized support, ready and wanting to help you walk through this time feeling held and seen.
How Therapy Can Help
Therapy can help by providing a space that is focused on caretaking of you, while so many others are focused on the wellbeing of the baby. In therapy you can explore and make sense of all the major changes that have happened, and process grief and overwhelm without judgment. You can increase your personal insight, strengthen your coping skills, improve self-compassion, and reduce feelings of loneliness and isolation. You can get connected to additional specialized and trusted referrals as appropriate, including some of the supports I mentioned above.
Over time, and with support, therapy can help integrate these new parts of yourself, reduce overwhelm, and build your confidence as a new parent.
What treatment may look like
There are many evidence-based therapy approaches that have proven effective for treating PMADs.
Cognitive Behavioral Therapy (CBT)
Interpersonal Psychotherapy (IPT)
Dialectical and Behavioral Therapy (DBT)
Exposure & Response Prevention (ERP) for OCD
Eye-Movement Desensitization and Reprocessing (EMDR) and Brainspotting for trauma
For a mental health crisis, such as postpartum psychosis, someone would require intensive in-patient treatment to stabilize before continuing treatment with medication and ongoing therapy.
I am an integrative therapist who pulls tools and techniques from many modalities depending on the presenting needs. If you’d like to read more in-depth about my approach to perinatal / postpartum work, you can find more here.
Taking the next step
If you are reading this today, and find that you are recognizing yourself in some of the symptoms, or you are feeling generally overwhelmed - I encourage you to reach out. I am always happy to offer a free 15-minute phone consultation to connect and see if it feels like a good fit. There is no pressure, I am happy when you feel supported, whether that is with me or with another provider. But if we chat and it feels good, I would be honored to support you as you walk through this wild life chapter.
Some resources:
Postpartum Support International Helpline: 1-800-944-4773
National Maternal Mental Health Hotline: 1-833-TLC-MAMA (text or call 24/7)
Perinatal Support Washington Warm Line (Peer Support Line): 1-888-404-7763
People in crisis should call their local emergency number or the Suicide & Crisis Lifeline at 988
Postpartum Psychosis Discussion Tool (by Postpartum Support International)
Perinatal Mental Health Discussion Tool (by Postpartum Support International)
International OCD Foundation - source of additional information for perinatal OCD
Sources for blog post:
Postpartum Support International: https://postpartum.net/perinatal-mental-health/
Policy Center for Maternal Mental Health: https://policycentermmh.org/mmh-disorders/