Postpartum mental health (aka: perinatal mental health or maternal mental health). It’s one of those things you don’t really think about until you get there. Then when you do, you find yourself with a handful of questions.
And you don’t know where to turn or how to do it. All the while, you’re balancing a baby in one arm, grabbing a cup of coffee from the microwave with the other and realizing the awful smell following you around in the house is actually you.
Well what if we could tap into someone’s brain to answer those questions? Someone with the clinical experience and the book knowledge. Maybe as a way for you to be proactive; or maybe because you are currently in the thick of things, and are looking for some courage to reach for the phone.
Luckily for you, I know just the person! Meet Cassie Rockweiler, MSW, LCSW, PMH-C (@the.mommy.therapist). Not only is she a licensed clinical social worker with 6 years of work under her belt. But she now holds a Perinatal Mental Health-Certification. AND she’s a mom. So she gets it.
A few months back I asked you guys over on Instagram for postpartum questions. Specifically questions you’d like to ask a therapist. And boy did you follow through! I reached out to Cassie with those questions, and because she is a rock-star, she answered them!
Who’s ready to shed some light on the elusive postpartum/perinatal mental health topic? We will talk red flags, what therapy looks like, alternatives to therapy and more!
First, Some Housekeeping
- Before we get into the questions, let’s get into the legal stuff. Please please please do not let this article take the place of therapy or medical advice. It is meant purely for educational purposes, and does not constitute a patient/provider relationship. Access to mental health resources in your area can be found at NAMI.org or by calling 1-800-950-NAMI.
- You’ll see PMADs mentioned below, which is probably a new term to many reading this. Basically its an umbrella term that encompasses maternal mental health issues during pregnancy and up to one year after delivery. According to Seleni Institute, PMADs “encompass a range of emotional disorders, including major depression, generalized anxiety, OCD, panic disorder, and PTSD. Symptoms vary in severity – from bothersome to debilitating – and PMADs can develop during pregnancy or at any point during the first year after giving birth.”
1. So Cassie, what is Perinatal Mental Health? I thought it was Postpartum Mental Health?
Great question! Using a term like perinatal paints a more accurate, inclusive picture when compared to postpartum.
Perinatal is defined as the time right before conception to right after birth, and in recent years this period has grown to encompass any time from trying to conceive all the way until 1 year after delivery. Some people take it more globally to cover the woman throughout her reproductive years.
So with all that in mind, Perinatal Mental Health focuses on the biological and psychological changes that can occur during the perinatal period, typically viewed as conception to 1 year after delivery.
You may also see maternal mental health being used more for the same reason.
2. Postpartum Depression (PPD) seems to be talked about frequently, but what about Postpartum Anxiety (PPA)? What are some red flags for PPA?
In the field we are actually moving from PPD to PMADs: Perinatal Mood and Anxiety Disorders. In the past, PPD was an all-encompassing diagnosis that included anxiety, depression, even psychosis. Which is why PPD was talked about frequently. But it was often misunderstood or not realized by many that PPA was lumped in there, too.
PPA red flags would be similar to Generalized Anxiety Disorder red flags: excessive worrying about one’s own health or baby’s health, agitation, restlessness, poor concentration, fatigue but unable to sleep, and increased physical complaints (stomachaches, headaches, muscle tension, etc).
One of the biggest signs of PPA is intrusive thoughts. These are thoughts that we know are irrational, but we are unable to let go of them. Something like, “I have to check on my sleeping baby every few minutes because I know they are going to stop breathing.” This pattern of behavior unfortunately does not help with these thoughts; it only perpetuates them.
3. How far out from delivery can a mother experience mental health changes?
After delivery a woman can experience symptoms very early. Most will experience some sort of “baby blues” due to rapid hormone swing immediately following birth. True mental health symptoms normally don’t present until two weeks postpartum, but can happen at any point within the 12 month period.
And a lesser known fact is mental health changes can happen even before delivery! One of the reasons that we have gone to PMADs is to include this time period— Postpartum Depression (PPD) only looks at the period of time after delivery.
Depending on a woman’s conception and pregnancy journey, she can experience mental health symptoms prior to the “typical” postpartum period. If she is struggling to get pregnant, has had multiple losses, has medical conditions during pregnancy (gestational diabetes, preeclampsia, etc), or fetus complications, these can all lead to mental health symptoms prior to delivery.
4. Is there a push to make Perinatal Mental Health look beyond 12 months postpartum?
I see this as two parts. The first is that beyond the 12 month mark if someone is still having symptoms, they currently would “crossover” into a general mental health diagnosis. This is also fuzzy because mental health symptoms can happen at ANY point within the first year. So at 11 months if someone starts feeling depressed that is considered PPD. But they might not seek therapy until months later.
As a provider, one of the goals is to see what the anxiety/depression is connected to. For PMADs, the symptoms are connected to the infant, motherhood or transition. If we start to see anxiety with her job, relationship, identity (not related to her infant), then that would be more indicative of a Major Depression/Generalized Anxiety diagnosis.
The second part is mothers later in life can experience a lot of symptoms that were never addressed from their postpartum period. They never regained intimacy with their partner, dealt with the grief over leaving their job, connected with their child, etc. These things have always been there, but they either put them to the side or didn’t see them. And the symptoms usually pop up again when their last child has gone to college or left the house.
I think that as this field grows we will start to look at women’s mental health differently due to the sheer number of hormonal changes and life transitions that we go through.
5. What signs should a mom, first time or otherwise, look for to know that things aren’t quite typical from a mental health perspective?
We want women to be their own advocate. If something doesn’t “feel right” then something isn’t right, and that feeling is enough to ask for help. The transition into motherhood is one that you can’t know until you are there. Even with another child or children, you’ve never been in this position before.
When I am assessing someone, I look for lack of self-care and attachment to the infant. Self-care tasks include sleeping, eating, and hygiene. If a new mother is eating okay, sleeping okay, and brushing her teeth, I consider her self care intact.
Sleeping is one that is tricky because you have a newborn. But even newborns sleep, and normally they have at least one 4-hour period a day. So you want to make sure that a mom is sleeping as much as she can.
The next factor is attachment. Not all mothers or fathers feel this overwhelming love for an infant at the beginning, but there should still be a bond. As an aside, I think knowing that not everyone feels an initial “overwhelming love” to their new infant is helpful in making parents feel “normal”.
Other warning signs should be if she struggles to care for the infant. You want to ask “Is this mother connecting?”, “Is she tending to the baby when they cry?” and “Is she feeding and changing regularly?”
6. How does someone seek help?
There are a few ways you can go about seeking help. The first would be to talk to your OB about what you are experiencing. The second option is you can always search for someone yourself.
You can do so by looking through lists provided by your insurance (call and ask for a list) or look on sites like psychologytoday.com (they have options to filter by age, gender, specialty, etc.)
I also suggest asking friends. So many people go to therapy. I promise if you ask a couple of your friends, you will find someone that goes to therapy. Also many cities have mom Facebook groups. This is how a lot of moms find me! Someone will post asking about therapists for “x,y,z” and they will say “Cassie is a specialized mom therapist!” So many different ways to go about it!
7. What is a typical first appointment for a new patient?
A typical new patient appointment will focus on the mother’s background. It can be anxiety provoking coming in and telling a complete stranger your business, so I try to make assessments as relaxed as possible.
There are things that a mom can struggle with that start earlier than postpartum, so we want to make sure we are asking and identifying those points. Depending on where she is in the perinatal period, I’ll go over her conception (miscarriages, infertility, etc), pregnancy (finding out, pregnancy symptoms, medical problems, etc.) and postpartum (delivery, newborn stage, etc) experiences. I will also start to ask about family planning, future children, relationship with spouse, etc.
We might go over therapy and what to expect in therapy. I might also ask to have a release for a psychiatrist or OB/GYN. This is important so that if anything medical or medication related comes up, we have a physician on board.
The assessment should take between an hour to an hour and a half.
8. What does treatment look like? Is medication usually a first step?
Treatment is different depending on who you see. I think that there is a misconception about psychiatry and the different people that work within the mental health field. I do not prescribe medication. Not because I have a problem with it– I don’t! But because it isn’t in my scope of practice.
As part of my job I try to keep up with medication side effects, dosages, and changes so that I can provide feedback to patients about their concerns with medication.
If you initially reach out to an OB/GYN for help, their natural reaction might be medication, but know that you always have the option to refuse or ask for alternatives. I try to always tell people that medication doesn’t have to be first line therapy. But there is also no shame in it. And if you feel your provider is pushing medication on you, then they probably aren’t the best provider for you.
9. Any proactive steps mothers can take other than therapy?
We get so caught up in the “talking” aspect of therapy that we rarely look at other possible factors that are influencing your mental health. I have my “4 Medications” that I discuss with all my patients: sleep, nutrition, exercise, and meditation. Doing these four things every day will significantly help mental health symptoms.
I know it is hard to get a good night’s rest, but it is probably the most important skill to work on. Getting good rest means that you are refreshed, able to concentrate, have good decision making skills and are less irritable.
I don’t necessarily say that patient’s should go on diets, but I do try to help them become aware of what they are putting in their body, as well as how they are caring for it. I like fast food just as much as the next person, but I feel significantly better when I am eating somewhat healthy and exercising.
As for meditation, it is common for moms to be “go go go” all the time. It’s good to take the time to slow down and re-center. Meditation isn’t about calming down or slowing down your mind. It is more about choosing your own speed—a speed that makes you feel comfortable. Plus, it’s a good way to have “you” time as well.
10. Any common threads you see regarding mental health stressors?
I think the biggest common threads I see are lack of socialization and genuine relationships. Many moms are very isolated due to the hustle and bustle of family schedules. We tell ourselves that Sue from ballet and Lisa from baseball are our friends, but in reality they are just acquaintances.
Women NEED other women; we are biologically programmed to this. It has been seen in breast cancer recurrence studies that women with stronger social groups have lower rates of returning cancer. This shows us that our bodies heal and do better when we have strong friendships and socialization.
The other aspect to relationships is the one with our spouse/partner. So many women struggle to have conversations with their spouse. The transition from couple to parents isn’t always discussed or thought of in the beginning. Many women tell me that their spouse returns to a “primitive” state and believes that women should do all the child rearing and household tasks.
Thankfully this thought pattern is changing, and with my younger patients I am seeing an active role from both parents with child rearing and household chores. These parents still struggle with the transition though, but the sharing of roles helps.
Your whole life changes. You use to be spontaneous and have sex wherever and whenever. Now you have to plan time with your spouse. And even then, sometimes the kids and your day wipes you out! There has been a big push for “dating your spouse” and I like it. Somewhat difficult with little kids, but definitely something that we should continue to promote to build better and more sustainable marriages/partnerships.
11. Can fathers experience perinatal anxiety or depression?
YES! Paternal depression happens in about 1 in 10 men. This also goes for non-gestational parents (LGBTQ+) as well as adoptive parents.
We are learning more about paternal depression and the many reasons that it presents. Some of the research indicates that partners experience depression or anxiety because of the stress put on their relationship. They see their partner struggling and they internalize their lack of being able to “help them”.
There is also some part of paternal depression that can be present because of the transition in the relationship. Partners can feel like they are on the back burner and that all their partner cares about is the baby.
It’s definitely an area that needs more research and is truly fascinating!
12. Do you have favorite resources?
My favorite is Postpartum Support International (linked below). They have so many available resources, like online groups for new mothers, NICU parents, military parents and Spanish speaking parents. They have coordinators that can help connect patients with resources in their areas. There is also a directory of people who are certified or have completed training in perinatal mental health.
13. Let’s talk about COVID-19 for a minute. What steps can a mother take to protect her mental health during this time?
This is a great question! So much of social distancing can feel like the beginning of a woman’s postpartum journey: stuck at home with a child/children with very little access to help or support.
The first way to protect yourself is to acknowledge that this sucks. I am telling patients regularly to not try and sugar coat COVID life.
The second is to work with your partner about creating time for yourself. It is so easy to get sucked in the everyday life of social isolation. We are now asked to be parents, teachers, playmates, chefs, counselors and more. This is so much more work than we are used to! Go get a limeade from Sonic, take a bath, go for a run. Allow yourself some time to relax and recharge.
Now that school life is approaching, I have also been suggesting keeping kids on a familiar routine. Try to keep the summer schedule to a minimum. This helps both them and you!
The last thing I like to remind patients is this isn’t going to last forever. If your kids are watching more Youtube right now, so be it! If they eat candy for breakfast, so be it! This isn’t “normal life”, so things will be off. Allow yourself to be flexible!
14. Lastly, when you think about the future of Perinatal Mental Health, what makes you the most hopeful?
When I was pregnant I became interested in Perinatal Mental Health because I noticed a lack of information available to moms. As I went through my pregnancy/parenting classes, there was very little discussion about the topic.
I knew there had to be more for us and that there had to be others who thought that moms deserved better. And there was!! I went to a mental health conference and there were so many people interested in the field.
It makes me happy to see that this field is growing more mainstream and that we are starting to grow within the community. There are more and more resources for anxiety, depression, grief and loss, paternal PMADs, infertility, etc.
I’m excited to see that places like California are making it a requirement for hospitals to provide PMH services and information. And I am excited to see that places are more open and willing to grow in this field.
The world that I thought was Perinatal Mental Health is so much bigger than I could ever imagine!
The sky’s the limit, and I can’t wait to see where it goes!
Let’s Sum It All Up
Here are some of the takeaways from today’s post:
- The mental health field is moving from postpartum to perinatal or maternal because the latter paints a more accurate, inclusive picture of the mental and physical effects that can occur during and after pregnancy.
- Anxiety red flags include excessive worrying about one’s own health or baby’s health, agitation, restlessness, poor concentration, fatigue but unable to sleep, and increased physical complaints (stomachaches, headaches, muscle tension, etc) and intrusive thoughts.
- There are a handful of ways to find a therapist or someone to talk to.
- Medication doesn’t have to be first line of treatment.
- Try including Cassie’s 4 “Medications” into your daily/weekly routine: sleep, nutrition, exercise and meditation.
- Spouses, partners, LGBTQ+ and adoptive parents can experience depression and anxiety, too.
Did anything else stand out to you?? Leave a comment below with yours! We would love to hear your thoughts!
- How to Work with Cassie: Ochsner Health
- Postpartum Mental Health Resources
- Post: Maternal Mental Health: Why it Matters by Cassie Rockweiler