Why screen for PMAD?
PMAD is the #1 medical complication of childbearing. The term PMAD (Perinatal mood and Anxiety Disorders) has replaced the narrow definition of PPD. This is essentially an umbrella term that can include depression, anxiety, obsessive-compulsive disorder (OCD), panic, post-traumatic stress disorder (PTSD), bipolar disorder and even psychosis.
Mental disorders have physical and physiological effects; studies have shown that depressive moods or anxiety during pregnancy correlate closely with low birth weight. Another important factor here is the occurrence PMAD; while 21% of mothers have some type of PMAD, only around 6% develop preeclampsia during pregnancy, yet the latter is screened for in virtually every pregnancy. All these factors reflect the importance of providing patients with the space to realize how the challenges of every day life can interfere with their wellbeing during and after their pregnancy. It also moves us as health professionals to refer and connect women and their partners with the resources necessary to move forward.
Tragic consequences of untreated PMAD include depression, anxiety, and other mental health concerns, marital issues, self-harming behaviors, issues with mother-child attachment, psychosis, and in extreme cases suicide and/or infanticide, to name a few.
- Around 80% of mothers experience baby blues
- 1/7 mothers experience anxiety/depression
- 1-2/1000 mothers experience postpartum psychosis
- Suicide is one of the three leading causes of maternal death.
Pregnant women need:
- A companion/advocate (e.g.: partner, relative, close friend, doula)
- Supportive professionals with mental health knowledge (medical, mental, social and educational)
- A time and place to be educated and voice their concerns honestly and openly
Many women succumb to the pressures of trying to be a Superwoman, attempting to take on all the challenges of motherhood virtually alone while attempting to maintain their happiness and sanity and caring for the people around them. Researchers and long time advocator for perinatal mental health, believe that women should break free from that notion and realize that as women and a mother we should have “seasons of giving and seasons of receiving”, and the perinatal period is definitely one of receiving.
The Postpartum Period
During this time, there is a shift of attention to the baby and mothers are often forgotten. They must learn to adapt to fatigue, hormonal changes, role transitions, mother-baby attachment, new roles and responsibilities, insecurities about parenting abilities, physical and emotional healing and even feelings of loss (loss of identity, body image, etc.). This is not an easy task and often times, mothers find themselves overwhelmed.
Most of us have heard of “baby blues” but what differentiates those from perinatal mood disorders? First off, the baby blues can last from two days to two weeks and the predominant mood in this time is happiness, even if there are episodes of tears or frustration. On the other hand, PMAD tend to linger past two weeks, even affecting mothers a couple years after their delivery, if left untreated. In the following sections, we will go through risk factors as well as each type of PMAD and what characterizes them.
Moreover, it is important to note that the mother is not the only one struggling to adapt; 10% of new father’s become depressed which can manifest as distance and irritability.
- Family/personal history of clinical depression, psychosis or bipolar disorder
- Significant mood reactions to hormonal changes
- Endocrine dysfunction
- Stressful social factors (finances, relationships, lack of support, etc)
- High stress parenting (multiparous patients, single parents, sick children, etc.)
- Complications in pregnancy, birth, and/or breastfeeding
- Age-related stressors
- Climate stressors
- “Superwoman” mentality/expectations
- Lack of sleep
- Abrupt discontinuation of breast feeding
- Career vs. motherhood dilemma
- Culture shock
- Unresolved grief/attachment to own mother
- Sleep disturbances (insomnia or hypersomnia)
- Loss of interest in things that used to be important
- Hopelessness, guilt and shame
- Low energy
- Poor concentration
- Appetite changes (over-eating or under-eating)
- Physical complaints (generally without medical reasons)
- Sadness and crying
- Suicidal ideation
Patients often describe being overwhelmed, feeling worthless and having a lack of feeling towards the baby. Anxiety and depression often come together.
Anxiety and Panic
- Excessive concern about baby’s health or her own health
- Appetite changes
- Constant worry/racing thoughts
- Heart palpitations
- Can present with or without panic attacks (during these, patients tend to voice three major fears: a fear of dying, going crazy and/or losing control)
Obsessive-Compulsive Disorder (OCD)
There are multiple types of OCD, the more traditional being people who compulsively clean, check or count, among other things, and tend to know that their actions are abnormal. Another type is that of repetitive and intrusive thoughts constantly bombarding their mind. In the postpartum period, these thoughts are usually of some type of harm coming to the baby.
- Intrusive, repetitive thoughts
- Engaging in distracting behaviors to minimize triggers
- Guilt and shame
One of the most important things to remind patients with this disorder is that thoughts DO NOT equal actions. In other words, just because you think about potential situations (like running away, for instance) does not mean those things will actually happen.
Post-Traumatic Stress Disorder (PTSD)
34% of women report a traumatic birth. This arises from a perception of a lack of caring in respect to the healthcare professionals providing services, poor communication that had a lasting impact, feelings of powerlessness and/or physical complications during pregnancy or during the actual childbirth. Additionally, PTSD from childbirth isn’t exclusive to the mother; it is something that can affect partners as well.
PTSD in the postpartum period can lead to:
- An avoidance of aftercare
- Impaired mother-baby bonding
- Sexual dysfunction
- Avoidance of further pregnancies
- Fear of invasive procedures
- Elective cesarean section
** Survivors of abuse may have PTSD that resurfaces during delivery. This can manifest as repugnance of blood or secretions, body memories of abuse, fear of invasive procedures or dissociation.
** Parents with babies in the Neonatal Intensive Care Unit (NICU) may also experience trauma.
Perinatal Psychosis is the prime thing we think of when we hear Post Partum Depression (PPD), especially since it has been sensationalized in the media. However, it only occurs in 1 to 2 of every 1,000 deliveries.
Most patients who develop postpartum psychosis have a family or personal history of psychosis or bipolar disorder while 45-52% of women with bipolar disorder found their symptoms exacerbated during pregnancy. It is important to consider that having a multidisciplinary support (psychiatric, medical, psychotherapy and social support) will decrease the probability of developing postpartum psychosis.
- Delusional thoughts (strange beliefs or thougths)
- Usually begins around three to four weeks after delivery
- Insomnia, confusion and disorientation
- Rapid mood swings
- Episodes of delusion and episodes of lucidity
What can we do to help patients with PMAD?
- Listening to their concerns without judgment
- Emphasis on self-care
- Referral to mental health professionals
- Support groups
- Social support
- Practical help
- Parenting classes
- Medical help