I am a physician assistant who began my medical
career in the intense environment of a hospital ICU. I loved the work and the
sense of urgency that came with it. As I transitioned into motherhood, however,
I found that the demanding hours were no longer feasible. Seeking a better
work-life balance, I moved into psychiatry, initially for what I jokingly
referred to as “Mommy hours.” Little did I know that this somewhat
unconventional move into psychiatry would not only align better with my
personal life but also unveil a profound professional passion.
During my early years in psychiatry, I realized
something that had been right under my nose: I had been suffering from
postpartum depression without recognizing it. Despite having a therapist and
being aware of the challenges of life, it wasn’t until I was immersed in the
field that I truly understood what I had been experiencing. This revelation was
life changing. Effective treatment improved my life immensely and sparked a
deep passion for psychiatry, especially for serving women during their childbearing
years and beyond. I became particularly interested in how hormonal fluctuations
impact a woman’s mental health.
* * *
In this article, I want to focus on a critical
aspect of women’s mental health: perinatal mood disorders. These conditions
encompass a range of emotional and psychological challenges that women may face
during pregnancy and after childbirth. Understanding how to recognize these
issues and seek appropriate help is crucial for the well-being of both the
mother and the baby as well as the entire family unit.
Perinatal mood disorders exist on a continuum,
ranging from depression and anxiety to bipolar disorder and psychosis. They can
manifest in various ways, and it is essential to distinguish between what might
be considered “normal” emotional fluctuations and more severe psychiatric
issues. For example, the “baby blues” are a normal phenomenon, in which a woman
may feel hyper-emotional in the first two weeks after childbirth due to the
rapid reduction in estrogen and progesterone levels in her body and brain. This
may include feeling more easily triggered to crying on both happy and sad
occasions. However, it should not include a deep sadness, thoughts of despair
or detachment, and/or an inability to separate from the baby.
Most recently, a mother who I treated for
postpartum depression and anxiety worried constantly about “everything” from politics to personal finances. She had
trouble falling asleep and when the baby would wake her for a feeding, she
struggled to return to sleep due to racing thoughts of anxiety. During the day
she felt immensely sad as if life was not worth living. She did not enjoy
spending time with the baby or her other three children and could barely take
care of her own personal hygiene or nutrition, preferring only to lay in bed.
This patient had a long history of depression with her first episode occurring
prior to having children. However, her condition worsened during her fourth
pregnancy and in the postpartum to the deepest depression she had ever
experienced. Chasdei Hashem, we were able to find a good combination of
medication to help bring her out of this depression. Today she is happily
taking care of both her children and herself as a stay at home mother.
Depression and bipolar disorder are two primary
mood disorders we encounter. Signs that something is amiss can include
disrupted sleep patterns, sadness, persistent irritability, anger or rage, and
significant changes in energy levels, ranging from extreme highs to
debilitating lows. Psychosis, although less common, is a severe condition
characterized by confusion, disorientation, and a loss of touch with reality.
Symptoms can include delusions – suspicious thoughts or beliefs that are unlikely
to be true, such as thinking someone is out to harm you or that you need to
harm others to “save” them – or hallucinations, seeing, hearing, or feeling
things that are not there. When a woman is in this state, she often cannot
recognize it herself due to the detachment from reality, so it becomes
extremely important for those around her, namely her spouse and other family
members, to be educated about this possibility. That way, it can be recognized
in a timely manner and treated appropriately with antipsychotic medication as this is not a condition that resolves on its own.
To
date, I have treated four women with postpartum psychosis. Most notably patient
A who, within two weeks of delivering her third baby girl, began to see things
around her shimmering and shining “as if the whole world were technicolor.” She
also saw “angels” with whom she would speak and heard messages from “G-d”
prophesying her as the next virgin mother of the messiah. She was possessed
with boundless energy and did not sleep for five full days. Her husband noted
that she was not communicating with him in a usual manner, that she would
seemingly look through him or appear to be talking to people that he couldn’t
see. Because treatment involves sedating medications, Patient A did require
hospitalization. Upon her release, we worked together to keep her mentally
stable with a combination of medication, therapy, and lifestyle modifications.
Today she is the happy mom of three girls, the youngest of whom is now two and
a half years old.
Anxiety disorders, including
obsessive-compulsive disorder (OCD), often go unrecognized during pregnancy and
in postpartum as well. Manifestations can include sleep disruption, racing
thoughts, and intrusive, distressing thoughts, often concerning the baby.
Mothers may experience vivid images of bad things happening or worry
excessively about the baby’s well-being, leading to behaviors like constantly
watching the baby breathe or hyper-fixation on feeding schedules, beyond a
pediatrician’s recommendations.
* * *
Several risk factors increase the likelihood of
developing perinatal mood disorders, including a history of mental health
conditions prior to pregnancy, family history of psychiatric disorders, and
adverse outcomes, such as NICU stays or breastfeeding difficulties.
Screening for perinatal mood disorders is vital.
The Edinburgh Postnatal Depression Scale (EPDS) is a valuable tool used during
pregnancy and postpartum to identify women at risk. In addition to the EPDS,
asking about/reporting to your doctor any intrusive thoughts and sleep
disruption is crucial. While some sleep disruption can be a normal part of
pregnancy, ongoing issues can elevate anxiety and lower mood, necessitating
intervention. The MGH Perinatal Depression Scale (MGHPDS) phone application is
another useful tool for monitoring symptoms.
There are specific vulnerability windows, during
which women are particularly susceptible to perinatal mood disorders. These
include the first trimester of pregnancy, around the 20-week mark, and the
third trimester just before delivery. In the postpartum, the most vulnerable
periods include the first month after delivery and the time period between four
and six months postpartum as well as the weaning phase, whenever that should
occur.
If you or someone you know is experiencing
symptoms of a perinatal mood disorder, seeking treatment with a therapist
(psychologist or social worker) is crucial. Behavioral therapies are an
essential part of coping, but sometimes medication is required, especially when
sleep disruption is involved or to provide the stability needed to engage in
therapeutic work fully.
Creating a safety plan is an essential step for
those at risk of severe perinatal mood disorders. The Brown-Stanley Safety Plan
Template is a helpful resource for developing a personalized safety plan. In
terms of resources, Psychology Today and
the PSI directory (Postpartum Support International) are excellent starting
points for finding mental health professionals.
If you’d like more information, specifically
about my practice, refer to my ad in this issue for my contact information.
Recognizing and addressing perinatal mood disorders is crucial for the health
and well-being of mothers, their spouses, and their children. By understanding
the signs, risk factors, and available resources, we can provide better support
and care for those navigating the challenges of pregnancy and postpartum mental
health.
Chaya Spigelman is a
physician assistant in psychiatry seeing patients in Maryland and via
telehealth in both Maryland and New York (additional state licensures f
