Maternal Mental Health: PMADs (Perinatal Mood and Anxiety Disorders)

Maternal mental health matters.  Anxiety and depression are the most common complications of childbirth, occurring in far higher numbers than gestational diabetes or hypertension.  Breastmilk and lactation is a secondary concern when a mom and/or the people around her are suffering.  It’s important to prioritize mental health care and treatment, giving families the tools they need to heal and thrive.

If you need help now, please call or text the FREE 24/7 National Maternal Mental Health Hotline (English/Spanish as well as 60 other languages) at 1-833-9-HELP4MOMS (1-833-943-5746).  More information about its services as well as the many languages counselors speak is available on its website.

Medical and lactation professionals must be aware of PMADs when caring for breastfeeding patients. Much of the postpartum time period focuses on infant feeding and growth. Therefore, a woman’s emotions often can be expressed via the lactation lens. This can range from moms who produce very little breastmilk feeling inadequate and ashamed to moms who become obsessed with pumping and are unable to stop. For others, pain becomes a central component of their breastfeeding experience. In many situations, women are the victim of mismanagement and justifiably angry at a medical system that doesn’t know how to help them. A condition called “DMER” (dysphoric milk ejection reflex) involves nausea, anxiety, and feelings of doom when a mother feels her milk letdown. Nursing aversion occurs when moms have negative feelings in general toward breastfeeding that can include annoyance, rage, and a feeling of wanting to escape touch. While they are not technically considered PMADs, they both resolve with the SSRI class of drugs and women can suffer considerably before receiving treatment.

Abstract painting of a woman holding her hands above her head
Rachel Yang, MD

Lactation, Anxiety and Depression

Depression and anxiety may be even more prevalent in those moms who experience challenging breastfeeding complications or struggle with baby weight gain or other health concerns. Untreated depression and anxiety can contribute to early cessation of breastfeeding, so it is important both for the mental health and physical health of new moms and babies to get on the path to feeling better. I often tell patients and other healthcare providers that you “can’t make breastfeeding better until you make mental health better.” A minor setback for a mom with untreated PMADs can be devastating, whereas others who have a stable mental health state can weather significant complications and continue breastfeeding.

We have learned that postpartum anxiety presents more frequently than postpartum depression in new moms, and many suffer from mixed symptoms. Intrusive thoughts are extremely common and can range from transient to repetitive and problematic.

We also know there are multiple “peaks” of PMADs, including six weeks, three months, and six months postpartum. But this doesn’t mean PMADs can’t occur at any other point — including more than a year postpartum. This period in a woman’s life represents a time of vast hormonal, emotional, and life change that it is experienced in unique ways for different individuals.  The Birth of a Mother Podcast does a wonderful job of exploring this topic.

Symptoms may be different than those women experience at other times in life. In addition to some of the emotions related to breastfeeding that I describe above, other common symptoms include insomnia, irritability, guilt, rage, difficulties with relationships, withdrawing from helpful people, and feeling disconnected from or not bonded with the baby. You may not love or even like your baby, and may feel significant resentment toward it. These feelings can be extremely distressing for women, and they may hesitate to share with anyone. However, it is important to recognize this is not uncommon and help is available.

Getting Help

Getting help is NOT a sign of weakness, “failure,” or “giving up” — in fact, it’s the opposite: you’re taking important steps to protect the health of you, your baby, and your family. Treatment may involve therapy and/or medication. If your physician believes you could benefit from medication, it is important to consider this advice. The vast majority of psychiatric medications are safe during pregnancy and lactation and using medications can in fact can help modulate adverse outcomes of depression on the fetal brain. Untreated mood and anxiety disorders during pregnancy increases the risk for low birth weight and preterm birth, and has well documented negative impacts on infant and child development.

A common misconception about SSRIs and other medication is that people won’t be “themselves.” In fact, it is completely the opposite: the goal of treating perinatal mood and anxiety disorders with medication is to remove the intrusive, debilitating, and distracting thoughts (that occur as a response to shifting estrogen and serotonin levels) in this time period. The goal is to restore your clarity of thinking so you can be present for your children and other people in your life.

When patients report “not liking” a SSRI in the past, this is often because the dosage wasn’t prescribed appropriately, or the patient simply wasn’t matched with the best SSRI for their symptoms. For example, Paxil is a SSRI that offers excellent treatment for OCD, PTSD, and panic. However, if the dosage is increased or decreased too suddenly, patients can suffer from side effects such as nausea, headache, and fatigue. So I encourage anyone who had a previous undesirable experience with a SSRI to try again with a provider who is very familiar with the unique perinatal period.

Another misconception about medication is that the medication will make “all the problems just magically disappear.” This is not the case at all. Normalizing serotonin levels simply allows moms to process their environment more clearly and work through postpartum challenges without continually being distracted by intrusive scary thoughts, debilitating depression, and other symptoms that disrupt daily functioning.

Painting showing a woman sitting on the ground looking down
Chloe Trayhurn

Phone Holiday

One thing you can do for immediate relief is take a “phone holiday.”  Make a shoebox and put your cell phone in it for 12 or even 24 hours.  This will give you a chance to quiet spinning thoughts, stop comparing yourself to others, re-center, and re-focus.  It also allows you to recognize how often you are turning to social media or google searches for advice or reassurance in moments of panic (most of the time, people report that they feel worse — not better — after being on their phone).  Keep a short handwritten record of your thoughts during this “phone holiday time.”

Phone Holiday
Japanese kintsugi pottery bowl
Kintsugi Pottery
Indigenous Colombian mother

It's a Marathon

Outside of lactation, the postpartum period is a time of profound physical and emotional change. Balancing a baby, family, partners and friends, work, pets, and preexisting or new life stressors as well as sleep deprivation can be extremely challenging. Birthing experiences can reactivate memories of past trauma or assault. We must recognize the significance of the “4th Trimester” and the need for comprehensive care of moms and babies.

Parenting and breastfeeding are a marathon and not a sprint. A new exercise regimen is easier to maintain if you start walking and continue at a reasonable pace, week after week, rather than running so hard that you stop in a few days because you dread it so much. Much of breastfeeding is recognizing the shades of “grey” rather than the “black and white.” You may have a setback, but it doesn’t mean you have failed at breastfeeding. 

Finally, while some women respond well to the idea of “meeting breastfeeding goals,” I am more cautious with this terminology. We want to support women and children, not define motherhood and breastfeeding as either “success” or “failure.” If a mom is anxious and depressed, pumping at all hours to meet a “goal” but losing her presence with her baby, partner, family, and community — this isn’t “success.” We want to honor the uniqueness of each mom and baby, supporting individual people rather than abstract and potentially unattainable “goals.” And we want to take parts of mom that may feel damaged, and make her whole again. Perinatal mental health therapists often refer to the Japanese art of kintsugi, in which broken ceramics are repaired with a beautiful lacquer. The breaks and repairs are thought to be part of the history of the object and are celebrated rather than hidden, with the transformative art piece representing something more precious than it was before.