PMADs: The Need-to-Knows

PMADs is the umbrella term used to address the 5 different clinical mental health conditions an individual may experience during pregnancy and/or up to 24 months postpartum (referred to as a perinatal period). These conditions include Postpartum Depression, Postpartum Anxiety including Obsessive-Compulsive Disorder (OCD) and Panic Disorder, as well as Postpartum Post-Traumatic Stress Disorder (PTSD), Perinatal Bipolar Disorder, and Postpartum Psychosis (in rare cases).

Since Postpartum Depression, or PPD, was the first identified, and later recognized clinical condition, it may be important to note that in the general public, PMADs are often incorrectly referred to as Postpartum Depression or simply “Postpartum.” However, as we began to pay better attention to what families go through during the perinatal period, PPD alone fails to represent the full range of what people were really experiencing. This awareness led to the necessary differentiation of the experiences and the identification of the above conditions.

Put bluntly – PMADs are common and PMADs can happen to anyone. Left undiagnosed or untreated PMADs can have a long-lasting and detrimental impact on the individual, child, family, and society at large.

PMADs are the number most common childbirth complication in the U.S. Currently, 20-25% of women or birthing individuals, and 1 in 7 (or 10) men, are expected to experience PMADs; however, medical experts believe PMADs to be much more common than these statistics suggest.

Great question. In short, the difference between normal, expected, or typical “new parent hard” and PMADs is the intensity, frequency, and duration of the symptoms.

However, it’s really hard to assess the above when one only has their own experience to compare it to. For that reason, self-assessment or “screening instruments” were created.  HERE is a link to two self-assessment tools you can use to objectively screen for both Postpartum Depression and Postpartum Anxiety.

Currently, all parents (mothers, fathers, adoptive, etc) are recommended to get screened or to screen themselves for PMADs during pregnancy and at 1, 3, 6, and 12 months Postpartum.

Please Note: Screening is not diagnosing. Results indicating the possibility of a PMAD should be confirmed by a qualified healthcare professional.

Still, while these tools are good, they are not perfect and one does not need to wait until an assessment demonstrates potential clinical distress to seek support.

The truth is, one can never have too much support during the perinatal period and the good news is, there is support available.

For local, specialized San Diego support:  

The Postpartum Health Alliance (PHA)

For specialized support outside of San Diego: 

Postpartum Support International (PSI)

PMADs do not discriminate. They can affect people from all races, ethnicities, cultures, and educational or economic backgrounds. Likewise, they are NOT anyone’s fault. PMADs do not demonstrate weakness, indicate personal or relationship issues, or reflect poor parenting or lack of love for a child. In fact, many people who go on to develop PMADs have no known risk factors.

That said, research has identified common biological, psychological, and environmental risk factors that may increase the likelihood of PMADs. This is helpful because identifying risk factors increase rates of early detection and treatment planning. Like anything, the more risk factors a person has, the more likely they are to experience PMADs.

PMADs may be unavoidable at times, but with the right preparation, potential prevention or early intervention of PMADs is absolutely possible!

Although what this looks like will vary by each individual, below are some areas of we recommend focusing on:

Get Informed – Being able to recognize risk factors and address PMAD triggers and symptoms is the first line of defense when it comes to managing mental health.

Establish a Strong Support Network – The perinatal period is a time to lean in on partners, family, and close friends. Still, due to the magnitude of the transition and role, additional outside peer and/or professional support are often warranted. A dedicated community support group (i.e. such as new moms groups) often provides many psychological benefits for both parent and baby.

Practice Stress Management – Pregnancy and parenthood can be very difficult experiences. Therefore it is important to intentionally maintain healthy levels of stress via practices and techniques like controlled breathing, meditation, and mental health breaks.

Don’t Slack on Physical Fitness – It is well documented that physical activity is beneficial to the body as well as the mind. That said, it’s important to be mindful of new limitations due to the changes in your body and adapt exercises as needed to prevent complications or injury.

Drink Water and Eat Right- This sounds basic and boring, but it’s common for such basic self-care practices to go out the window in response to the new demands and time constraints a newborn brings.

Prioritize 4-6 Consecutive Hours of sleep a day/night – It’ll take help and some creativity (especially if exclusively breastfeeding), but making sure each caregiver is able to receive at least four consecutive hours of sleep is critical in preventing the compounding and biologically unavoidable effects of sleep deprivation.

See a Reproductive Psychiatrist for Medication Management – The benefits of medication(s) many outweigh the risks of not taking the medication, yet many MDs or psychiatrists aren’t equipped to lead the nuanced discussions necessary to make these decisions. Pregnant or breastfeeding individuals should seek out a Reproduction Psychiatrist when it comes to medication management during the perinatal period.

Work with a Mental Health Specialist – Don’t attempt to do all the above alone. Get professional help. A trained and licensed mental healthcare professional has the experience and tools necessary to guide individuals and families through this though all of the above.

In general, PMADs are effectively treated by:

Step 1. Evaluation – Often the first and hardest step in treatment is to initiate or undergo an evaluation. Some amazing doctor’s offices automatically administer screening assessments or questionnaires as a part of their postpartum care practices, but sadly this is not the norm.

If concerned, reach out to your doctor and directly request an evaluation. In doing so, doctors will likely discuss your concerns and symptoms with you to make a treatment plan or refer you to a mental health professional.

You can also connect directly with a mental health professional. A mental health professional will likely use a screening tool to assess your symptoms, in addition to collecting and reviewing an in-depth psycho-social assessment history to best understand the ins and outs of the client’s circumstances and experience.

Step 2. Treatment – Once the specifics of your symptoms, circumstances and personal needs are identified, your provider will make treatment recommendations. Treatment for PMADs can range depending on the severity of the condition (e.g., whether your symptoms are mild, moderate, or severe).

Counseling or psychotherapy is usually recommended for mild or moderate symptoms. While individual needs and therapeutic approaches will vary, to address PMADs symptoms, providers will likely incorporate an approach that is short-term and solutions-oriented to obtain relief quickly. Some will choose to discontinue therapy once they feel better for a sustained amount of time. Others may seek out additional therapeutic benefits by opting for longer-term treatment.

Medication, in combination with therapy, may be warranted in more moderate or severe cases of PMADs. Master’s level therapists and psychologists cannot prescribe medication, but most will be able to assist you in working with an MD or Reproductive Psychiatrist who can. Should medication be utilized, treatment would consist of medication management via the prescribing doctor and continuation of therapy via the original provider.

In rare cases, severe cases may require intensive outpatient or inpatient treatment programs, if the management of symptoms through medication and outpatient therapy alone is not effective or sufficient.

Lastly, the incorporation of general wellness and proactive mental health practices are always explored and encouraged throughout all stages of care.

Typically mental health conditions present on a spectrum of mild to server. The severity or personal/familial impact of the symptoms most often determined the urgency of care; HOWEVER, there are several rare yet significant symptoms one might experience that would immediately indicate a medical emergency.

Emergency symptoms are:

• Signs of postpartum psychosis (link)
• Any thoughts involving an active desire or plan of suicide
• Any urges to harm baby or another person

If any of the above occur, call 911, the San Diego also has a Psychological Emergency Response Team (PERT), or go directly to your nearest emergency room.

If you are ever unsure about what to do, call a crisis line and seek their guidance. Here trained professionals are available to support you and assist in identifying next steps.

San Diego Access & Crisis Line

1-888-724-7240; TTY: 619-641-6992

National Suicide Prevention Lifeline

1-800-273-TALK (8255);  Spanish/Español: 1-888-628-9454

For local, San Diego Support to go –

The Postpartum Health Alliance (PHA)

• Online Provider Directory
• List of Perinatal Community and Support Groups
• Warmline (Get support and resources from a trained volunteer)
• Educational resources

For support outside of San Diego to go-

Postpartum Support International (PSI)

• National Helpline that’ll connect you to your local resource
• National Provider Directory
• National, free online support groups

Additional, Therapist Directories –

Psychologytoday.com

What’s important to know is that PMADS are not the same thing as “Baby Blues,” which are experienced by up to 80% of mothers or birthing individuals.

The Baby Blues is largely thought to be the result of acute sleep deprivation plus hormones dropping 4-5 days postpartum. For this reason, the Baby Blues usually starts within a few days of giving birth, last a week or two, and then fade away on their own.

While during this time one’s predominant mood is happiness, most new moms or birthing individuals report also feeling uncharacteristically weepy, drained, anxious, irritable, and overwhelmed.

Meaning… if a woman is exhausted, emotional, and experiencing difficulties sleeping directly after giving birth, then that might just mean she just gave birth! She and her body need support and time to recover from one of the most natural, yet supernatural experiences of her life.

Still, if any of the following warning signs occur, it is essential to check in with a doctor and/or a perinatal professional to make sure she is not experiencing something more:

• The symptoms last longer than a couple of weeks
• The symptoms seem to be increasing in frequency or intensity
• The symptoms are interrupting her ability to function
• The symptoms entail delusional beliefs, hallucinations, manic or erratic behavior, insomnia, or other symptoms of Postpartum Psychosis (these are a medical emergency)
• She or you are concerned (aka always trust your gut!)

Perinatal or Postpartum Depression (PPD) is probably the PMADS that you might have heard of before and illustrated in media (think Brooke Shields and Megan Markle).

Most parents experience some form of mood changes during and after pregnancy but around 15-20% of women go on to develop PPD (after baby is born). The symptoms can look similar to Baby Blues, but the main differentiator is the duration, frequency, and intensity. If symptoms last past 2 weeks and emotions/behaviors are interfering or overshadowing day-to-day life, it might be PPD. If you or your loved one are experiencing any of the symptoms listed below please speak with your healthcare provider.

• Feelings of anger or irritability
• Lack of interest in the baby
• Appetite and sleep disturbance
• Crying and sadness
• Feelings of guilt, shame or hopelessness
• Loss of interest, joy or pleasure in things you used to enjoy
• Possible thoughts of harming the baby or yourself

Perinatal or Postpartum Anxiety (PPA) or Panic Disorder

You know when someone says not to worry and then it makes you more worried, well anxiety, especially for first-time parents, is completely normal so don’t worry! 😉 

But… when you start feeling like you’re losing control and not yourself and experience intrusive thoughts that interfere with normal, daily functioning and intense fear, these might be signs of PPA. PPA is now suspected to be the most common PMADs as it is expected to impact as many as 1 in 4 women.

Sometimes the anxiety can manifest with physical symptoms such as panic attacks, and you may experience shortness of breath, chest pain, claustrophobia, dizziness, heart palpitations, and numbness and tingling in the extremities. Panic attacks can come and go but know that they will pass and do not create long-term damage.

Full Symptom list –

• Hypochondriasis (about own health or baby’s)
• Constant worrying about baby, avoidance of activities
• Panic attacks
• Trouble sleeping
• Agitated, Irritable
• Inability to sit still
• Racing thoughts
• Heart palpitations, shortness of breath

Occurring in 5-11% of postpartum women, Perinatal women are 1.5-2x more likely than the general population to develop OCD. Why?

When one considers how overwhelming and vulnerable the transition into parenthood is, it is understandable one might unconsciously begin to engage in behaviors that give them some sense of control. However, when repetitive patterns of behaviors start to occur in order to reduce anxiety such as nonstop cleaning, checking the same thing over and over (an irrational amount of times), “researching” until into the wee hours of the night, and counting or reordering/organizing, then these might be signs of PPOCD.

Oftentimes, PPOCD includes intrusive and repetitive thoughts about harm coming to baby. Because of this, one might experience fear of being alone with baby, hyper-vigilance around protecting baby, and scary or uncomfortable thoughts that repeat or last throughout the day related to baby.

These thoughts often feel very unsettling and many have a difficult time admitting them out loud. That said, 70-80% of moms are dealing with intrusive thoughts. The thoughts are totally normal and nothing to feel ashamed about. Being able to manage and “unhook” yourself from the thoughts is the difference between someone with typical intrusive thoughts and someone experiencing PPOCD.

Typically steaming from a traumatic birth experience, PP-PTSD can also be a result of or triggered by non-birth-related experienced, i.e. breastfeeding, NICU, interactions with staff, etc.

What is essential to understand is what has considered a traumatic event is different for everyone. We all experience and respond to trauma differently. PTSD is simply the brain staying in a heightened state of emergency after exposure to a traumatic event (real or perceived threat or loss of safety).

It’s important to assess and consider PTSD as the symptoms can easily be confused with other mental health disorders, but the treatment looks significantly different. For example, anxiety is a really common symptom of PTSD but it’s treated quite differently.

Common signs of PTSD are:

• Flashbacks
• Distressing thoughts or feelings about events
• Recurrent dreams or nightmares
• Avoidance of triggers
• Persistent and distorted sense of blame
• Numbing
• Hyperarousal/Hypervigilance
• Heart palpitations, shortness of breath

Perinatal Bipolar disorder is one of the least talked about and understood PMADs. Here are some high-level need-to-knows:

• Bipolar Disorder is a chronic disorder that is managed with medication. Left untreated, those living with bipolar are at risk of high rates of relapse, suicide, and psychological dysfunction.
• 50% of those diagnosed with BD are diagnosed for the first time during the postpartum period (coincides with the general population commonly diagnosed between 18-30 years of age).
• 60% are often misdiagnosed with depression.
• 71% of women diagnosed with bipolar disorder will experience a reoccurrence during pregnancy.

Not familiar with Bipolar Disorder? Here’s a quick overview..

Mood changes from high to low and vice versa. The low period is clinically called depression, and the high is called mania or hypomania. Symptoms last for 4 days or more and impact day-to-day life and relationships. The cycling of emotional states is more than just feeling irritable during pregnancy or postpartum. It can look like major depression or anxiety.

There are two subtypes. In Bipolar II, the manic episode is a lot less severe and apparent than it is in Bipolar I and oftentimes the individual may not even know they are experiencing it until a loved one notices it.

Specific to the postpartum period, whether the caregiver is in a depressed or manic phase, the ability to care for baby will be impacted if the caregiver goes untreated. Due to the nature of this disorder, left untreated individuals are at a higher risk of suicide or harming self or her baby. Therefore it is imperative that the caregiver is assessed and properly treated if they are experiencing any of the following:

• Elevated mood or periods of severely depressed mood/irritability/anxiety
• Decreased need for sleep
• Over-average productivity or rapid speech
• Impulsiveness or racing thoughts

If you or someone you know might be experiencing Perinatal Bipolar Disorder please consult a professional so that the caregiver can have a proper mental health assessment and receive the treatment they need during pregnancy, postpartum, and beyond.

For one, it is very rare, experienced by 1 to 2 out of every 1,000 birthing individuals. Although rare, Postpartum Psychosis (PPP) is a true medical emergency.

Left untreated, Postpartum Psychosis can have tragic outcomes. These are the devastating “posptartum” stories we hear about in the news or that are often depleted in Hollywood movies (Spoiler Alert: Tully and Shutter Island). Along with the missed opportunity to educate the public about the severe, unique, and rare symptoms associated with PPP, these preventable and horrific outcomes unjustly misrepresent and further stigmatize all perinatal conditions and experiences.

What should be highlighted, are the key features of PPP; such as, PPP typically comes on very suddenly (often the first couple of weeks after birth). Loved ones are critical in the observation of and response to symptoms onset, as the “bizarre” thoughts and behaviors resulting from the psychosis feel “normal” to the affected individual. Those with personal or family histories of Biopolar disorder or other psychotic episodes are at a higher risk of experiencing PPP. PPP is temporary and treatable, as long as immediate medical intervention is received.

PPP symptoms can include:

• Rapidly changing moods (manic-depression)
• Delusional beliefs
• Visual or auditory hallucinations
• Insomnia
• Disorganized behavior, Rapid mood swings
• Thoughts about harming baby that aren’t identify as irrational
• Waxing and waning (presents normal for stretches of time in-between psychotic symptoms).

If any of the above occur, call 911, the San Diego also has a Psychological Emergency Response Team (PERT), or go directly to your nearest emergency room.

If you are ever unsure about what to do, call a crisis line and seek their guidance. Here trained professionals are available to support you and assist in identifying next steps.

San Diego Access & Crisis Line

1-888-724-7240; TTY: 619-641-6992

National Suicide Prevention Lifeline

1-800-273-TALK (8255);  Spanish/Español: 1-888-628-9454