What You Should Know About Perinatal Mood and Anxiety Disorders (PMADs)!

Shannon M. Clark, MD
June 13, 2020
What You Should Know About Perinatal Mood and Anxiety Disorders (PMADs)!

Dr. Shannon M. Clark was joined by perinatal psychiatrist, Dr. Nichelle Haynes, to discuss perinatal mood and anxiety disorders. Below is a summary of the discussion and the full YouTube video!

What qualifies as a “perinatal mood and anxiety disorder”? When can PMADs occur?

Depression, anxiety, PTSD, bipolar disorder, obsessive-compulsive disorder, and psychosis. They can occur at any time during the pregnancy and during the postpartum period. Perinatal mood and anxiety disorders (PMAD), can have effects on mom before, during, and after pregnancy, with symptoms further magnifying after delivery because of the new-mom stressors like lack of sleep, hormonal shifts, and psychosocial status.

What comorbid medical conditions can be related to mood disorders?

Thyroid disease, anemia, vitamin deficiencies (B12, folate), and substance use disorders.

What are risk factors for depression?

  • Depression during pregnancy:
  •  Maternal anxiety
  •  Life stress
  •  History of depression
  •  Lack of social support
  •  Unintended pregnancy
  •  Medicaid insurance
  •  Domestic violence
  •  Lower income
  •  Lower education
  •  Smoking
  •  Single status
  •  Poor relationship quality
  • Postpartum depression:
  •  Depression during pregnancy
  •  Anxiety during pregnancy
  •  Experiencing stressful life events during pregnancy or the early postpartum     period
  •  Traumatic birth experience
  •  Preterm birth/infant admission to neonatal intensive care
  •  Low levels of social support
  •  Previous history of depression
  •  Breastfeeding problems

What about anxiety during pregnancy and the postpartum period?

Anxiety lies on a spectrum. Most new mothers, especially first-time mothers, are prone to experiencing some anxiety in the postpartum period. It might include worries about whether the baby will be safe, is eating or sleeping enough and if you are doing a good enough job as a mother. All of these feelings and fears are normal!. A low level of anxiety, especially in the early days, is an adaptive feature for mothers to stay alert for their baby’s safety. However, postpartum anxiety becomes problematic when it consumes every second of every day. For example, if anxiety prevents you from sleeping, making typically easy decisions or driving anywhere with your baby for fear something will happen, then it might be starting to become problematic.

Postpartum anxiety does not mean you’re crazy or paranoid. Anxiety is very real. It is not something you are making up, nor does it say anything about your ability to be a mother or how well you are coping. Between the significant hormonal shifts that occur after childbirth and the sleep deprivation, added responsibilities and physical healing after delivery, there are many triggers for you to develop anxiety.

Symptoms of pregnancy-related and postpartum anxiety:

  • Feeling dread or like something bad will happen
  • Constant worry
  • Racing thoughts
  • Sleep or appetite disturbances
  • Restlessness
  • Dizziness, hot flashes, nausea, stomach pain, shortness of breath

What treatments are available?

Mild symptoms: Therapy, support options (ie. Individual psychotherapy (interpersonal therapy, cognitive behavioral therapy, Self-care plan for sleep, diet and exercise, or group psychotherapy), possible medications.

Moderate symptoms: Same as above, but strongly consider medications, and consider referral or consult with a mental health care provider.

Severe symptoms: Same as above, but refer patient to a mental health care provider.

It is much more common for women to develop feelings of anxiety and low or irritable mood during pregnancy than one might expect. The good news is that treatment options are plentiful to help manage these symptoms and allow a woman to have a positive and enjoyable pregnancy. The traditional treatments we often consider include psychotherapy and medications. However, there are many more complimentary treatment options to explore. This includes massage for mood, acupuncture, light box therapy, folic acid supplementation, and omega-3s. To learn more about each one, read Complimentary and Alternative Treatment Options for Mood Symptoms in Pregnancy.

When are medications recommended? What are typical prescribing practices?

Medications are recommended for moderate or severe symptoms, or other co-morbid conditions (like anxiety, h/o other mood disorders). SSRIs are the best studied classes of medications in pregnancy. For many women, benefits outweigh the risks. If a woman needs treatment with a medication, we use what has worked for patient in the past, use lowest effective dose, minimize switching medications (if patient has been on a medication at a therapeutic dose for 4-8 weeks with no help, may need to change medication), monotherapy is preferred if possible, we may need to adjust the dose (if symptoms are better, but not resolved, can increase dose), and we do not recommend stopping SSRIs prior to delivery. Common antidepressants used in pregnancy are Zoloft, Celexa, Lexapro, and Prozac.

If a woman enters pregnancy already controlled on a medication, should she stop it or change it?

It’s best to continue medications that are already working in someone who is pregnant or lactating.

There is no “risk-free” decision when it comes to treatment for PMADs.

Women take many medications in pregnancy that are not known to be 100% safe. The same goes for medications for PMADs. An untreated or undertreated pregnant woman with a PMAD during pregnancy and lactation can be just as risky for the pregnancy as any medication given to treat the PMAD.

How can women be more involved in their treatment plan?

There are effective treatment options during pregnancy and lactation. You can call your insurance carrier to see what therapists and psychiatrists are available. Postpartum Support International is a great resource. Also, MCPAP For Moms, and Lifeline4Moms.

When should you contact your obstetricical care provider or mental health professional?

If these symptoms are impairing your ability to care for your baby, go about your daily routine or your ability to rest is limited, please contact a mental health professional or obstetrician.

Shannon M. Clark, MD

Shannon M. Clark, MD

Shannon M. Clark, MD, MMS is a double board certified ObGyn and Maternal-Fetal Medicine Specialist, and founder of Babies After 35. In her roles as a clinician, educator and researcher at UTMB-Galveston, she focuses on the care of people with maternal and/or fetal complications of pregnancy. Dr. Clark has taken a special interest in pregnancy after the age of 35, which according to age alone, is considered a high-risk pregnancy. In her role as a physician caring for high-risk pregnancies, she has counseled and treated hundreds of women over the years in her very own situation, and has found a whole new respect for the challenges and complications a woman may experience when trying to have a baby later in life.

Follow Shannon on TikTok @tiktokbabydoc, Facebook @babiesafter35, and Instagram @babiesafter35.

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