Understanding Postpartum Mental Health

EAP Ask the Expert: Leena Mittal, MD, Chief, Division of Women’s Mental Health, Brigham & Women’s Hospital

Recent difficult events affecting our local communities and workforce have shed light on postpartum mental health. Depression, anxiety and other mental health issues in the perinatal time (during and up to one year post pregnancy) are not always clearly understood and often stigmatized. Even with many cases going unreported, statistics show that perinatal mental health issues are quite common, and most are highly treatable. According to the CDC:

• 1 in 8 women have symptoms of postpartum depression (PPD)
• Mental health & substance misuse are leading causes of maternal mortality, with 4 out of 5 maternal deaths being preventable

We are fortunate to have experts (nurses, midwives, obstetricians, pediatricians/primary care, and psychiatrists) across Mass General Brigham (MGB), who provide skilled treatment, consultation, and education. To recognize Maternal Mental Health Month, the EAP is partnering with one of these experts, Leena Mittal, MD, from Brigham and Women’s Psychiatry.   She discusses how increased awareness and knowledge about perinatal mental health can minimize stigma, improve prevention, and lead to more positive outcomes.

Stigma leads to Misconceptions and Decreases the Likelihood of Intervention

In previous features, we addressed stigma and shame associated with mental health in general, but certain disorders or circumstances may trigger greater stigma. Dr. Mittal indicates that this is the case with perinatal mental health, which includes depression, anxiety and in rare cases, psychosis. Stigma can impact providers’ ability to recognize and address mental health conditions, and patients’ acknowledgment of their own struggle and willingness to seek help.

Much of the stigma stems from misconceptions including:

• A lack of understanding about how common mood and anxiety disorders are in pregnancy and during the postpartum period. People may feel that they are the only ones who feels down or anxious
  -In reality, these conditions represent a significant number of complications of pregnancy
• The perception that this is supposed to be a joyous time
  – In reality, pregnancy and the postpartum period are accompanied by a full spectrum of emotions
• Beliefs that there are not treatments available during pregnancy and breastfeeding that are effective and safe for moms and babies
  -In reality, there are many effective treatments, including medications, that can be used during and after pregnancy

Common Conditions during the Perinatal Period

The conditions listed below can occur alone or in combination. The important thing to remember is that there is help available and a significant likelihood of improvement.

Baby Blues

Baby blues, which occur during the first few weeks post-delivery, are quite common (in 75-90% of moms) and are associated with an increase in emotional reactivity. This means being more tearful, but not necessarily meeting criteria for being classified as persistently “down and depressed.” Typically, no formal treatment is needed for baby blues, as this condition generally resolves on its own. However, self-care and support from family and friends can be helpful.

Depression

Postpartum depression (PPD) affects at least 12.5% of mom’s post-delivery and is a more significant clinical condition with an advanced set of symptoms, such as:

• Persistent low mood (lasting more than 2 weeks)
• Poor self-appraisal and negative cognitions, such as guilt or self-deprecation
• Impacts on everyday functioning
• Interruption to sleep, appetite, and concentration
• Lack of interest or energy
• Thoughts of self-harm or suicidality

PPD typically requires some type of intervention or treatment, such as therapy and/or medication.

Anxiety

Postpartum anxiety occurs in approximately 10% of mothers, and as is generally the case with anxiety disorders, involves intrusive thoughts and ruminating (repetitive, negative thinking). Anxiety disorders are responsive to medication, therapy (including cognitive behavioral therapy) and lifestyle interventions.

Psychosis

Postpartum Psychosis (PPP) is not common and occurs in approximately 0.1-0.2% of births. Psychosis involves losing touch with reality, is accompanied by delusions/false beliefs, and is often associated with complications from bipolar or depressive disorders. Dr. Mittal explains that one challenging component of postpartum psychosis is that symptoms can wax and wane or even be fleeting. Psychosis requires psychiatric treatment. When associated with risk of harm to self or others, psychosis is a psychiatric emergency and warrants immediate evaluation. It has been estimated that untreated PPP carries a 4% risk of infanticide and a 5% risk of suicide. As discussed in our feature on suicide, most threats of suicide or other violence associated with mental health conditions are rare, but treatable. Unfortunately, there are some outcomes (occurring very rarely) that are simply not preventable, regardless of the skill level of the treating provider.

Who is at Risk for Perinatal Mental Health Challenges?

Anyone can be at risk because hormonal changes can have unpredictable impacts but causation is usually multifactorial. Dr. Mittal strongly recommends universal screening, before, during and after delivery, regardless of risk.

All parents who give birth

There are some experiences that make all moms at risk for mental health complications postpartum:

• The act of going through childbirth itself
• Hormonal changes
• Sleep disturbance
• Psychological impacts of transitions
  – First-time parent, new baby, changing family dynamics

Those with a mental health history and life stressors

There are red flags that may put some individuals on the radar in advance. The sooner clinicians know about the potential to develop symptoms, the better position they are in to anticipate and treat complications. Some risk factors include:

• Prior history of depression, other mood disorder and/or anxiety
  – Dr. Mittal explains that abrupt hormonal fluctuations or mood issues alone can be impactful but mood and/or anxiety symptoms, combined with hormonal fluctuation is a major risk factor
• Prior history of perinatal mental health issues
• Family history (particularly a first degree relative) of a perinatal mood and or anxiety disorder
• Having a substance use disorder
• Other life stressors

Partners & Dads

Partners and dads may also experience perinatal mental health effects. Dr. Mittal indicates that this is particularly common in cases with complex pregnancies or deliveries.

Suggestions for Prevention

For all parents who give birth

Do some work upfront:

• Understand how common mental health conditions are in the perinatal phase
  – Learn about the biology of the impacts of pregnancy and hormones
• Build a team – nursing service, friends, family, (and lactation support if breastfeeding is a goal)
• Consider in advance how you can maximize measures that will support self-care and functioning, with:
  – Sleep
  – Nutrition
  – Caregiver bonding time
• Plan to attend postpartum visits for you and well-baby visits with your baby’s pediatrician. These are important opportunities for wellness checks and the chance to speak with providers about your physical and emotional health

For those with a general or postpartum mental health history

Dr. Mittal refers to planning for those with a pre-existing history as “secondary prevention.” This entails:

• Understanding what pre-disposes you to complications
• Early conversations with providers to be prepared and proactive
• Establishing an advance plan (such as a psychiatric advanced care directive) for when you may not be in a healthy enough state with the appropriate insights/ability to make this plan
  -Identify supports and treatment options

For family and friends

• Educate yourself about perinatal mental health – risks, warning signs and supports
• Discuss postpartum plans
• Know who the providers are so you can share concerns with them or attend appointments
• Offer reassurance that you are an available support during all phases
• Set the tone that checking in about this is no different than checking in about other medical conditions

Supports and Treatment

Most perinatal mental health conditions are highly treatable. For some, self-help through peer support or engaging in healthy lifestyle activities might be adequate but others may benefit from or require professional help.

Peer supports & resources

Use of peer support (individually or via groups) allows for connection with other parents and families going through similar experiences and stresses. Below are some resources for finding groups for parents and families:

• Postpartum Support International (PSI)
• MCPAP for Moms
• PSI – Help for Dads
• PSI – Help for Queer & Trans Parents

Healthy Lifestyle

Self-care helps to manage stress and promotes positive mental health outcomes. Consider focusing on:

• Sleep
• Healthy Eating
• Exercise
• Mindfulness
• Social connection

Professional Assistance

As discussed above, expert help is warranted in the most extreme circumstances, such as danger to self or others, but also appropriate in many less severe cases. Moderate presentations of anxiety, depression (or other mood disorder) can be burdensome for the individual and family. Untreated mental health conditions can pose a risk to the well-being of the baby and family functioning.

Effective interventions offer an increased likelihood of sustained relief and healthy engagement. Getting help for these issues is no different than seeking assistance for other pregnancy-related complications, such as high blood pressure or diabetes. Commonly, a combination of treatments can provide the most positive results.

• Medications – many of the same psychopharmacology treatments that are helpful outside of the pregnancy and postpartum context are also safe and reasonable options for perinatal anxiety, depression or other mood disorders. Use of these medications is supported by a large body of research and bolstered by consultation with clinical experts in perinatal psychiatry. As with any medication, some adjustment might be necessary at certain junctures and it’s important to discuss side effects or concerns with your provider
• Therapy – such as psychotherapy, cognitive behavioral therapy and interpersonal therapy are potentially effective modalities
• Other Interventions – when conditions are resistant to first-line treatments, there are other options, such as ECT

Help for Providers

Our system has many experienced experts (across multiple disciplines) skilled in evaluating and treating perinatal mental health issues, but clinicians who are not as familiar with perinatal mental health are also likely to interface with patients dealing with these challenges. While not all cases are preventable or easily resolved, most women and families can be helped. Dr. Mittal recommends the following for maximized clinical care:

• Universal Screening -not just when there is a concern. Risk is not always immediately apparent and it’s important to eliminate any bias that might be associated with deciding who should be screened
  – Screening should ideally be addressed in primary care and OB, with the use of experts (psychiatry) as needed in complex cases
• Avoiding silos – via multi-disciplinary (PCP, OB, pediatrician, nursing, mental health) collaboration and consultation for a family care approach
• Using services that offer provider to provider consultation via experts
  – MCPAP for Moms – Provider access network
  – Perinatal Psychiatric Access Program
  – MGH Psychiatry Academy – Perinatal Mental Health Courses for Providers

Resources

MGB

• BWH – Women’s Mental Health Services
• MGH Center for Women’s Mental Health – Reproductive Psychiatry Resource & Information Center
• WDH – Postpartum Mental Health
• MGB Groups – Coping with Stress & Emotions during Pregnancy & Postpartum
• BWH Video on Post-Partum Depression, Featuring Leena Mittal, MD
• EAP Postpartum Resources

Community Resources 

• Postpartum Support International
  – Massachusetts Chapter
  – New Hampshire Chapter
• MCPAP for Moms
• Mass.Gov – Postpartum Depression Resources for Mothers

Suicide Prevention

• Suicide Prevention and Supports
  – National Maternal Mental Health Hotline
  1-833-943-5746-
• 988 – Suicide & Crisis Lifeline
  – Dial or Chat
• Samaritans – Suicide Prevention
  877-870-4673 or Text

Help from the EAP
The EAP offers free and confidential services for employees and immediate household family members. EAP records are separate from medical and HR records. Contact the EAP at 866-724-4327 or request an appointment via our online form for confidential assistance. In-person appointments are available at the following locations. Phone or Video (Zoom) appointments are available from all locations.