Meet Christine. She is a married 30-year-old woman who just had her first baby about 3 weeks ago. While the pregnancy went smoothly, the experience of labor and delivery was difficult. After nearly 20 hours of labor, Christine had an emergency caesarean section. The baby was healthy, but he had difficulty breastfeeding. Christine was worried that she was not producing enough milk. Her baby lost more than 10% of his weight during the first week, and Christine was forced to supplement with formula.
Christine went to see her obstetrician two weeks after delivery because she was worried that her C-section incision site was infected. Her obstetrician reassured her that there were no signs of infection but was concerned because Christine was not her usual self. She was tearful and reported that she was having problems falling asleep, fearful that something might happen to her baby. Christine’s obstetrician set up an appointment for Christine to meet with the OB social worker the following week.
When Christine met with the OB social worker, she denied feeling depressed. She acknowledged feeling sleep-deprived, unable to sleep restfully and persistently worried about the baby’s health and his ability to gain enough weight. Although her mother was willing to help care for the baby, Christine did not feel comfortable leaving the baby with others. When she was away from the baby, she was plagued by persistent, intrusive thoughts of something horrible happening to the baby — for example, the baby suffocating in his bed sheets.
Christine is not an actual patient but an amalgam of the postpartum women we see at our clinic. During the postpartum period, there is a confluence of many significant events: recuperation from labor and delivery, sleep-deprivation, breastfeeding, negotiating the transition to parenthood. During the first few weeks, many new parents may recognize that things are not going well but may not be able to distinguish what is normal and what is a problem.
Postpartum Depression or Postpartum Anxiety?
Postpartum depression first gained medical attention in the 1970’s. Like depression which occurs at other times in a woman’s life, researchers observed that postpartum depression is characterized by feelings of sadness, irritability, tearfulness, appetite changes, and sleep disturbance. But what we have learned over time is that many women with what we typically call “postpartum depression” also have significant anxiety symptoms.
This most commonly takes the form of generalized anxiety, persistent and excessive worries, feelings of tension, and inability to relax. Often these worries are focused on the baby, his or her health and safety.
Many postpartum women have symptoms consistent with obsessive-compulsive disorder (OCD). Obsessional thoughts are experienced as intrusive, unwanted and inconsistent with one’s typical personality or behavior, and patients often express fears of even thinking these thoughts, particularly when they involve thoughts of harm to their baby. One study demonstrated that 57% of women with postpartum onset major depression reported obsessional thoughts (as compared to 36% of women with non-postpartum major depression). In addition, women with postpartum obsessional thoughts had more frequent obsessional thoughts than women with non-postpartum obsessional thoughts.
How postpartum depression and postpartum anxiety relate to one another is not fully understood. Clinically, it seems that women with more severe depressive symptoms also have comorbid anxiety symptoms. We do see non-depressed postpartum women with generalized anxiety disorder (GAD) or OCD; however, it seems that many women who have postpartum GAD and OCD ultimately report some depressive symptoms, especially when their symptoms are more severe or prolonged.
A recent study attempts to better understand the relationship between postpartum depression and anxiety. This was a prospective study of obstetric patients (n=461) recruited immediately after delivery and followed for 6 months; 331 (72 %) of the women completed the assessment at 6 months postpartum.
At 2 weeks postpartum, 28 (19.9 %) of the women with depression had anxiety symptoms, compared to 4 (1.3 %) of the women who screened negative for depression (p?<?0.001). Similarly, 36 (25.7 %) women with depression endorsed obsessions and compulsions compared to 19 (8.4 %) women without depression (p?<?0.001). Anxiety symptoms seemed to subside over time. By 6 months postpartum, there were no differences in symptoms between women with and without depression. Conversely, the differences in obsessions and compulsions between depressed and non-depressed women persisted.
Does It Matter? Do We Need to Distinguish Between the Two?
As we move toward universal screening of postpartum women, it is interesting to note that many of the tools commonly used to identify women with postpartum depression also detect women with postpartum anxiety. For example, the Edinburgh Postnatal Depression Scale (EPDS) consistently identifies women with anxiety symptoms and total EPDS scores appear to correlate with disorder type. Women with no disorder have the lowest scores, followed by women with anxiety only, then by women with depression only. Finally, women with a combination of depression and anxiety scored the highest of the four. While these screening tools may not give us diagnostic accuracy, they do identify women with clinically significant symptoms who may benefit from treatment.
Distinguishing between postpartum depression and anxiety will help us to make better treatment recommendations. Women with milder symptoms may benefit from psychotherapy. While interpersonal therapy (IPT) benefits women with postpartum depression, we don’t really know how IPT works for OCD or generalized anxiety symptoms. In contrast, we have ample data from both postpartum and non-postpartum populations to indicate that cognitive-behavioral therapy (CBT) is an effective treatment for depression, OCD, and anxiety symptoms.
When it comes to pharmacotherapy, the antidepressants most commonly use to treat women with postpartum illness – serotonin uptake inhibitors (SSRIs and SNRIs) — are effective for the treatment of major depression, generalized anxiety disorder, and OCD. Bupropion is not as effective for managing anxiety symptoms and OCD. Women with comorbid depression and anxiety may also benefit from treatment with an anxiolytic medication, such as lorazepam (Ativan) or clonazepam (Klonopin), to help manage anxiety symptoms and sleep disturbance while waiting for the antidepressant to take effect.
While this question has not been adequately studied, it appears clinically that women with comorbid depression and anxiety may have more severe illness and may be more difficult to treat. According to current guidelines, it is recommended that women with more severe postpartum illness be treated with psychotherapy and medication. This may be particularly an issue with obsessional thoughts where symptoms are more refractive to treatment and CBT alone appears to be less effective than CBT plus medication.
Ruta Nonacs, MD PhD
Miller ES, Hoxha D, Wisner KL, Gossett DR. The impact of perinatal depression on the evolution of anxiety and obsessive-compulsive symptoms. Arch Womens Ment Health. 2015 Jun;18(3):457-61.
Wisner KL, Peindl KS, et al. (1999). Obsessions and compulsions in women with postpartum depression. J Clin Psychiatry 60(3): 176-80.
Loved this and the other articles. As a Clinical Teacher, looking to implement PPD Screening at intake. Thank you
I am 5 months pp with my first child and I feel that I was not adequately screened or treated. I was asked at my child’s first 3 appointments to complete a survey about how I was feeling, then the feelings were no longer addressed moving forward. Since the day I gave birth, I was told by three pediatricians and my obgyn that there’s nothing I can take for ppd and ppa since I am breastfeeding, and therefore I just have to “deal with it the best I can”. I was literally told those words. I have fought off the depression the best I can however the anxiety continues to get worse, which is causing the depression to return. Getting ready to seek treatment in the form of talk therapy. I believe it is important to follow postpartum women much longer because adjusting to a new life as a mother has been rewarding yet scary. In addition to going back to work while still having a breastfed infant who wakes for night feedings, being thrown into a new life routine can be difficult to navigate.
I am so sorry to hear about your experience. I know that there are many other women who have had the same response from their treaters. There are many medications which we believe are compatible with breastfeeding and pose minimal risk to the nursing infant.
You can find more information here:
You might want to find a treater in your area that has expertise in the treatment of postpartum depression and anxiety. Postpartum Support International or PSI at postpartum.net maintains a list of providers in the US and in many other countries.
My fiance just had our little girl 2 weeks ago and is very anxious and overwhelmed and emotional about everything. She says she isn’t depressed and doesn’t feel any resentment towards our child because in her mind postpartum depression means resentment towards our baby. She claims it is only postpartum anxiety and if I even try to bring up the term postpartum depression she instantly goes on the defense and tells me why it’s postpartum anxiety. Before our daughter was even born she told me she wanted to be a stay at home mom and do the nursing and housework while I was being the provider and bringing home the money and financial stuff on my end. Now that I’m back at work and doing everything we planned to do months in advance I’m being told by her that I work too late and I don’t help her with the baby. I work with animals and my job requires me to be on my feet all day and provide care for animals that can’t care for themselves and since it’s a very tiring job I told her on the days I work I’d like her to care for the baby and then the 3 days I have off I would care for her. I figured this is a good compromise seeing as how I need my sleep in order to perform well at my job with enough energy and she was in agreement. No problems right? Well the thing is she’s always super emotional and overwhelmed and always finds a reason to get mad at something. If I forget to do something or I don’t do it fast enough to her liking I get yelled at for it. I work late because one, it’s more hours for a better paycheck but also because I fear going home just to get yelled at by her for something or another at some point. I’m basically avoiding any conflict or argument with her as a way to preserve our relationship yet still trying to have a positive relationship with her and not avoid her entirely. I want to have a great relationship with her and my daughter yet if I swaddle my daughter in a way that she thinks is too tight or if she spits out her pacifier and it hits the floor it becomes my fault and she does this thing where she gives me a judgemental sigh or scoff of disapprovement. I just want us to be happy and I feel like I’m walking on eggshells just to avoid any arguments or ways to make her upset. I’ve voiced everything I’m mentioning here including my avoiding her as a way to not start arguments since everything has to be done a certain way by her standards and it didn’t help by being honest either. So if honesty isn’t helping and she wont even consider for a second that she may have postpartum depression (because it’s just postpartum anxiety) what can I do to preserve this relationship? Bite my tongue and just let her walk over me and get her way? Pretend that I’m fine with the way she micromanages everything I do when it comes to providing care for our daughter? I have to be the strong one for both of them and I feel like I have been to the point where I’m not even caring for my own personal well being. I don’t think I’m depressed but I am saddened that our relationship isn’t what it once was and it sucks but I feel like things won’t ever be better for us. I love them both but I feel like our relationship is either dwindling or at a standstill. If I cant even suggest the words postpartum depression and my being honest with her doesn’t help then what else can I do? Do I need medication to just ride things out until things hopefully get better? I know she won’t even take medication because she has taken all sorts of meds since she was younger and completely avoids them at all costs now. So I’m uncertain as to what I can do in my position and would like to know if anything I’ve shared points in the direction of postpartum depression or is it really just postpartum anxiety? Are they the same thing or are they completely different? Do they go hand in hand even though it doesn’t necessarily mean depression but feeling overwhelmed and anxious? I just am looking for some answers since this is our first time as parents and I’m trying to do everything right. She has a short temper and I know she would never do anything to harm our child, but her anger leads her to say really hurtful things whenever she gets mad enough and she doesn’t know how to be patient with me or on call nurses on the phone even. She gets frosted and hands the phone to me to deal with them because she gets upset and starts yelling. I’m trying to always be the calm and understanding person while she’s more explosive and quick to get angry. Is there anything I should do at this point to try to fix the situation or should I just ride it out and hope things get better?
I loved this article. Thank you for being so open to sharing your experiences. Postpartum anxiety is a topic that is often misunderstood and overlooked. It’s time we start talking more about postpartum anxiety to ensure that every woman gets the help she needs to get through such a difficult time.
One of my friends has postpartum depression, she becomes lonely after giving birth to a lovely child. She becomes paranoid when her husband goes anywhere and accuses him of having an affair when it’s not.