You’ve Heard of Postpartum Depression, But Probably Not Postpartum Anxiety

Four days after the birth of our daughter, my husband and I brought her home from the hospital. We were exhausted but giddy, ready to start our new lives. For nine months I had imagined what those first weeks at home would be like: sleepless nights, bleary-eyed arguments, a few late-night tears, all bundled up in the soft happy glow of new motherhood. In short, an adventure. But none of that materialized. What I came up against instead was a sheer wall of blinding panic.

We had left the hospital with instructions to wake our newborn up every three hours to feed, but by the time we got home and settled in, five hours had elapsed, and nothing would rouse her long enough to nurse. She lay limp in my arms, drifting in and out of sleep, howling uncontrollably just long enough to tire herself out. We took our cues from the internet and tickled her feet with ice cubes, placed wet towels on her head and blew onto her face, but only managed to upset her more.

And somewhere between trying to persuade her to latch for what felt like the hundredth time and willing my body to stay awake, it struck me that I had made a terrible mistake, one that I could never unmake. My stomach lurched, my hands and feet went numb and my heart began to pound.

These feelings weren’t new. Panic and I have a long and storied history together. But they were surprising. Even though my team of obstetricians had known I was on antidepressants throughout my pregnancy for an anxiety disorder, no one had thought to tell me I was at high risk for postpartum anxiety. And so when it hit me, I had never even heard of it.

And I’m not alone. According to some estimates, postpartum anxiety (ppa) affects up to 15 percent of pregnant and postpartum women, making the condition at least as prevalent as postpartum depression (ppd). (Postpartum is actually a misnomer, since the symptoms can hit anytime during pregnancy or after birth. A more accurate descriptor is perinatal, encompassing the months on either side of childbirth.) In some it’s experienced as negative intrusive thoughts, including thoughts of harming themselves or their babies. In other, ppa manifests as obsessive worrying, watching the baby’s chest rise and fall all night to make sure she’s breathing. And in a smaller group, including me, the anxiety is diffuse and nebulous but all consuming. What’s common in all cases is a paralyzing worry, often accompanied by an inability to eat, sleep, function in any meaningful way, and, most critically, to connect with an infant.

“Everything in a woman’s life is changing”, says Sheryl Green, a psychologist at McMaster University who specializes in women’s health. “It makes sense to have a little bit of anxiety. When it comes to the point that it’s debilitating […]—that is when people need to get formal treatment, just as they would with depression.”

Green began her career working at a women’s clinic, and “kept getting referrals for pregnant and postpartum women who had primary anxiety,” she recalls. “So I went to turn to resources and protocols to start treating these women effectively, and there was nothing there.”

The condition is not listed in the Diagnostic and Statistical Manual of Mental Disorders (the DSM), which is supposed to be the gold standard of reference for mental health professionals. Whether or not a disorder is included can also impact insurance companies’ willingness to cover treatment for it. “It’s just not on people’s radars,” says Green.

It certainly wasn’t on my radar. And in my case, the anxiety was annoyingly meta: I became terrified that the fever-pitched panic would never abate. Unlike a lot of new moms, I wasn’t obsessing over my daughter’s breathing, her heart rate, whether she would wake from her next nap. But I was convinced that panic had become my new normal, that something had snapped in me and would never unsnap.

In the weeks that followed, I fantasized for the first time in my life about getting hit by a bus, or not waking up in the morning. Every time my baby cried I became physically ill, an ironic reminder of the morning sickness I had just left behind. I felt nothing for her, just a tightening in my chest and a hopelessness that’s hard to explain. It seemed absurd that I should be her mother, very much a nightmare I couldn’t wake up from. She and I couldn’t possibly exist harmoniously in the world, I decided, and the only way out was for one of us to disappear.

And it didn’t help that my mother asked me if I’d ever felt such love before, or that distant relatives were making long distance phone calls to find out whether I was nursing—an uncle I had only met a handful of times in my life was suddenly interested in the nutritional value of my breasts. By this point I hadn’t eaten a proper meal in weeks, and my milk had all but dried up, but the pressure to nurse didn’t let up, and I pumped every two hours round the clock. But since tears were more forthcoming than milk, I eventually stopped trying altogether.

Green eventually decided to develop her own treatment protocol based around cognitive behavioral therapy, which is currently being piloted with a group of pregnant and postpartum women. The preliminary results are promising, and the research is currently under review by the Journal of Clinical Psychiatry.

Like Green, psychiatrist Nichole Fairbrother at the University of British Columbia arrived at research into perinatal mood disorders after uncovering a gaping hole in the literature. Her career path was defined by a thought that would have petrified many new moms. After her son was born, she remembers looking at his little hands, and thinking how easy it would be to cut his fingers off. “What would it be like to have a thought like that if I didn’t know anything about [negative intrusive thoughts]?” she wondered. “It would be terrifying. In that moment I really needed to find out: is anybody studying this? Is this a thing?” The answer was a resounding no.

Her lab published a landmark paper that found the incidence of ppa to be at least as high as ppd. “We weren’t surprised,” she says. “But it was validating.” Now, they’re focused on finding treatments that don’t involve pharmacological interventions, because drugs have been shown to have adverse effects on the developing fetus. “If there’s any population that deserves non-medication based treatments, it’s new mothers,” she says. “These women deserve an alternative.“

Unlike postpartum anxiety, postpartum depression has made its way into the common vernacular around early motherhood. In its mildest form, it’s called the “baby blues”, and is experienced by up to 80 percent of new moms, according to the National Institute of Mental Health. Although scientists don’t know for certain what causes it, It’s probably brought on in part by the sudden hormonal changes experienced after childbirth. A woman’s brain is bathed in a cocktail of hormones, including estrogen and progesterone, throughout her pregnancy, but after she gives birth the levels plummet almost instantly.

This withdrawal, coupled with the ordeal of pushing a baby out (or having it cut out of you) makes new moms very vulnerable to mood swings, weepiness, and irritability. And it’s no longer the taboo it once was: the discharging nurse at our hospital told a group of new dads, my husband included, that if their partners weren’t having at least one public breakdown a day, it was only because they were sobbing alone in the bathroom.

But postpartum depression is not the same as the baby blues, and what tips some women over the edge from mild weepiness to major depressive disorder remains, in part, a mystery. Over the past decade, there has been a steady rise in academic and clinical research around ppd, but the same cannot be said for ppa. A search of academic articles including the terms perinatal or postpartum depression yields 6488 results, with just 191 for perinatal or postpartum anxiety.

 Why the discrepancy? Maybe we just don’t know how to talk about debilitating anxiety in motherhood. While the baby blues gave us a common language for discussing sadness and depression, anxiety is so often dismissed as normal. New mothers are expected to feel overwhelmed and anxious—it’s par for the course.

“There’s a lot of misinformation and miseducation around what is common and or normal in the postpartum period,” says Paige Bellenbaum, social worker and co-founder of the Motherhood Center, a space in New York City offering a range of treatment options for women suffering from perinatal mood and anxiety disorders. Women experiencing anxiety or intrusive thoughts might “think they’re crazy and they’re not fit to be a mother,” she says. “It’s probably easier to talk about feeling sad or weepy than it is to say I feel completely anxious. I can’t sleep, I can’t eat. I’m hypervigilant. I keep having these very intrusive thoughts.”

I eventually found my way to the Motherhood Center, and to Bellenbaum, where a combination of Cognitive Behavioral Therapy, Dialectical Behavioral Therapy and psychiatric treatments over the course of 6 weeks helped me find a semblance of normalcy once again. I was admitted into their day program, a partial hospitalization requiring my daughter and I to be at the center five hours a day, five days a week.

Bellenbaum suffered from ppd herself, and co-founded the center when she realized how little help there was for women out there. “When I finally did get the treatment I needed,” she recalls, “I got really angry that nobody was talking about it [ppd], and nobody asked me how I was doing. Even when I had described my symptoms, nobody was able to tell me what it was that was happening.”

As wonderful as day programs are, they can be prohibitively expensive, and most insurance carriers will not reimburse for it. Nor will they pay for drugs to treat postpartum depression: just last week, the first FDA-approved treatment for ppd was announced, with a price tag of $30,000. “Health insurance companies sadly don’t value women’s mental health. It’s been a real uphill battle,” says Bellenbaum. ”There’s a lot of work that needs to be done around bringing costs down.”

Thanks to people like Bellenbaum, who spearheaded legislation around ppd screening in New York State, awareness of maternal mental health is on the rise, and treatment clinics are slowly beginning to appear around the country. But the screening procedures remain woefully inadequate. Most prenatal clinics administer a questionnaire designed to identify at risk women sometime during the first trimester, and then again at the six-week postpartum visit.

But for many women, these check-ins come either too early or too late. And even the best-intentioned providers can make women feel inadequate: At my six-week visit, the doctor took one look at my daughter and cooed, “Aren’t you just so in love with this little bundle?” I looked her in the eye, and pronounced an emphatic no. Needless to say, she looked terribly uncomfortable. She had me fill out the questionnaire, perused my responses and eyed me with concern: “Oh, you’re going to score pretty high on the depression scale.” No shit, I thought to myself.

The most commonly used screen is the Edinburgh Postnatal Depression Scale. Though it does include questions about anxiety, it’s mostly focused on depression.

“There’s a desperate need for measures to screen for perinatal anxiety disorders,” says Fairbrother. “It’s going to be really tricky to treat if we don’t have screens.”

What’s more, screening without an increase in awareness and education is just not going to cut it. More and more women are getting screened, but they may lie because of a reluctance to admit they’re having thoughts of self-harm or of harming their baby. Providers can also be part of the problem: “I’ve heard stories of nurses taking screens before a women is discharged from the hospital and saying: ‘I really think you should fill this out again,’” says Bellenbaum. “If I give this to the doctor, they’re not going to let you go home with the baby.”

I eventually found my stride with my daughter, and am beginning to imagine a world where the two of us can live happily side by side. I can’t state with any certainty whether it was the medication, therapy, or just time that began the healing process—most likely it was some combination of the three (and it doesn’t hurt that my daughter started to smile and coo right around the time I was all but ready to give up). What I do know with certainty is that motherhood is hard, and no one should be made to feel isolated and inadequate for having feelings that are so devastatingly commonplace.



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