Nappies and night feeds and nap schedules, oh my, the weeks and months after having a baby – as well as the pregnancy that came before it – can be a wild ride.
Adjusting to your new identity as a parent, if it’s your first, or changing dynamics in the home if you’ve added to an existing brood, is challenging for most new mums and dads. Throw in sleep deprivation, hormonal fluctuations, isolation from adult peers and other pressures, and new parenthood is a time when our mental health can be at its most vulnerable.
So, how can we take care of ourselves at this time, and what signs indicate that increased worry or tearfulness is moving beyond the ‘baby blues’, and should be flagged with a health professional? We asked Dr Emma Black, Clinical Perinatal Psychologist, to share her expertise on mental health in the perinatal period (that’s the time during pregnancy and the first year after a baby is born) - and what postnatal depression and anxiety can look like in new parents.
How can people understand the difference between the baby blues and postnatal depression?
“The symptoms can be similar, so it can be confusing. Both the baby blues and depression can involve feeling low or sad, irritable or angry, tearful, overwhelmed, confused, and with changes in appetite and sleeping. However, the major differences are that in depression the low mood, tearfulness, or loss of enjoyment tends to occur most days, for most of the day. In the baby blues, the symptoms are more transient; for example, you might suddenly find yourself crying about the mess in your house, but after your cry, you feel better again. The baby blues often has more emotional ups and downs than in Postnatal Depression (PND) - it can be more of a rollercoaster ride; whereas in depression, mood is consistently low. Depression symptoms will also be more severe.
Postnatal depression can occur anytime in the year after birth, whilst the baby blues specifically occur within the two weeks post-birth. The baby blues often starts around day 3 or 4 post-birth, and typically relieves by 2 weeks after birth (often resolving around Day 10). Essentially, if you’re feeling poorly more than two weeks after birth, it could be depression.
If there is a loss of interest or enjoyment in things you would usually like, this is depression (not the baby blues). Depression can also involve other symptoms not present in the baby blues, such as feeling really guilty or worthless (like your baby would be better off without you); difficulty concentrating; difficulty thinking; thoughts about death, dying, or suicide; lack of energy; tiredness and fatigue; or feeling slowed down, or agitated.
The baby blues is far more common than depression, affecting up to 76% of women after birth; whereas postnatal depression occurs in up to 20% of women.”
What are some things many people don’t understand about postnatal depression?
“It’s not just feeling sad, tearful or low – in fact, sometimes this doesn’t happen at all. Instead, people might feel flat, empty, not motivated to do things, and not feel much enjoyment or interest in things they would usually like doing.
PND can also involve irritability, anger, or rage too- women might find themselves having a very short fuse.
Often new mums can think that they’re having a hard time because motherhood is hard, they’re sleep deprived, and they’re not coping - but these can also be signs of PND, particularly if they have trouble sleeping when baby is asleep overnight, or have changes in their appetite and eating too.
PND can interfere with bonding with your baby (although not in every case).
Also, fathers can experience PND too - not just mothers!”
Why is it important to seek professional support if you suspect you have postnatal depression?
“Experiencing PND can be a high-risk time for women: thoughts of suicide or dying can occur. Combined with the many life changes (having a baby, going on maternity leave, relationship changes and more conflict in couples, more isolation for mums, and learning how to parent a new baby or additional baby, combined with sleep disruption), mums can be vulnerable to suicide or thoughts of suicide.
PND typically responds well to treatment, whether that is therapy, medication, or both therapy and medication. However, without help, it often doesn’t improve on its own.”
How about perinatal anxiety – is it true this affects over a third of women in the period during pregnancy and the year after birth?
“Yes! Perinatal anxiety is more common than PND. One study found it affects up to 39% of women postnatally. Perinatal anxiety refers to hard-to-control or excessive worry. This can be about the pregnancy (for example, worrying about making it to term, when there is no cause for concern), about birth. Postnatally, worry is typically about baby (for example, if they will nap on time, how their feeding is, their settling, whether they will make it through the night. Mums can worry about SIDS a lot; being apart from their baby, and more). There can also be worry about other concerns outside of pregnancy, birth and baby, such as returning to work, contact with relatives, and more.
There are other symptoms of perinatal anxiety too, such as insomnia or unrefreshing sleep, typically feeling tense, being irritable or having a short fuse, being angry, feeling tired and lethargic, difficulty concentrating, or having a mind that goes blank at times. There can also be panic attacks.”
What are some of the common risk factors for perinatal mental health challenges?
- An unwanted or unplanned pregnancy
- A difficult or traumatic pregnancy (for example, concerns over losing the baby; hyperemesis gravidarum, and more)
- Birth trauma
- Previous pregnancy loss/es
- Difficulty conceiving (fertility challenges)
- Losing your baby (.e.g, miscarriage, stillbirth, needing a termination for medical reasons
- A past history of mental health concerns such as depression or anxiety
- Being a younger age (i.e., under 25 years)
- Domestic violence
- Past traumatic events
- Stressful life events, such as a lack of social support, financial stress, and relationship conflict
What are some other mental health conditions that new parents should be aware of?
“Perinatal PTSD (P-PTSD)
This can be due to birth trauma (which affects one in three women); serious health conditions (such as hyperemesis gravidarum during pregnancy); babies going to NICU post-birth, unexpected or invasive medical intervention; or anything else that causes fear or distress.
P-PTSD is characterised by reliving the trauma (such as through nightmares, intrusive memories, or flashbacks), distress when reminded of the traumatic event, trying to avoid reminders of the traumatic event (for example, wanting to avoid hospitals, birth stories, another pregnancy, or talking about the trauma), having negative thoughts or feelings, and having difficulty relaxing or feeling calm (for example, having a short fuse, having trouble sleeping, being easily startled, and more).
Postpartum Obsessive Compulsive Disorder (OCD)
After birth, many women experience worrying and intrusive thoughts about bad things happening to baby. However, when this occurs a lot (daily, and repeatedly throughout the day), it can be considered an ‘obsession’; and when you feel compelled to do rituals to prevent these bad outcomes, these are known as ‘compulsions’.
The rituals are often hard to shake; women feel they must do them, even if they aren’t logically going to prevent the feared outcome. For example, worrying a lot about leaving baby in a car might result in a ritual of touching the car a certain way every time you get in and out of it, and touching baby repeatedly when in the house, to make sure baby doesn’t get left in the car. People don’t need to have both obsessions and compulsions to have OCD; it can be one or the other.
This involves episodes of intense anger that are difficult to control. There are outbursts, and sometimes this can involve yelling, throwing, or hitting things. Often women feel guilty, ashamed, and awful afterwards. People can dwell on things that frustrate them, then reach a peak where they end up exploding. And then because women try so hard not to do it again, things can just build up until the cycle repeats itself. Postpartum rage can be part of postpartum anxiety, depression, P-PTSD, or occur on its own.
Dysphoric- Milk Ejection Reflex (D-MER)
D-MER is specifically linked to breastfeeding. This is when the let-down reflex during breastfeeding triggers a flood of negative thoughts, feelings, or body sensations. Women can suddenly feel anxious and panicky, a sense of dread, tearful or low, irritation or anger, suddenly have negative thoughts about yourself or baby (and anything, really), and thoughts of death. There may be physical sensations such as feeling restless, like your skin is crawling, or your nerves are being grated. These feelings typically fade away after the let-down or when baby stops feeding. It can feel relentless however, to be feeling this way every time you feed, particularly as breastfeeding takes up many hours of the day.
Postpartum psychosis is a serious (but not common) condition which can involve hallucinations (experiencing things that aren’t there for other people, such as hearing voices, seeing images, or unusual smells) or delusions. Delusions are fixed, untrue beliefs that are unshakeable, for example, believing that other people are controlling your thoughts. Postpartum psychosis benefits from medical intervention first and foremost.”
What are some things that research shows are most effective in supporting women suffering perinatal mental health challenges to return to mental wellbeing?
Cognitive Behaviour Therapy
CBT has a good evidence-base in this period, and ideally with someone who is a perinatal therapist.
Engaging in pleasant events each day (or most days is probably more feasible!) can really help. Pleasant events involve engaging in activities that you enjoy doing, or at least used to enjoy doing, even if it is just for 20 minutes. In the perinatal period, pleasant events may involve things like reading a book, having a bath (either alone, or with baby), or taking baby for a walk - they don’t have to be ‘big’ things.
Practicing some type of relaxation is also helpful; for example, there is good evidence that practicing controlled breathing is helpful for reducing anxiety and stress in the perinatal period. This is where you control your breath - ideally in for 3 counts, out for 6; or if this is hard, just having an exhale longer than your inhale. This can be done as needed (e.g., when you feel overwhelmed or panicky). There’s evidence that practicing routinely, such as for 5 mins a day, can help bring down anxiety and stress over time.
There is also good evidence for pregnancy yoga helping with antenatal anxiety and improving overall wellbeing.
There is some evidence that practicing mindfulness can help too. This can also be done to help bonding with baby, for example, paying full attention to kicks and movements during pregnancy, and giving baby your full attention for small periods each day - you can try to notice everything you can about them, even if it’s just for one minute.
Social connection is also important, particularly as women can become isolated in this time of their lives.
Get a phsyical check-up
It’s also important to have bloods done with your GP in the postpartum period. Giving birth and breastfeeding take a toll on your body, and sometimes there can be physical explanations for what look like mental health symptoms.
While it’s not ‘evidence-based’ per se, women often need practical help after having a baby - which can reduce their stress, thereby helping their overall wellbeing. This can be things like hiring a cleaner, having friends and family help with meals or with chores around the home; negotiating the division of chores within the home with their partner; or having someone watch baby just so mum can get a nap in. These types of practical help and support go a long way towards helping a mum cope.