By Emma Svanberg, @mumologist
Today is #worldmentalhealthday. You might shrug that off as just another ‘hashtag day’ on Instagram, or it might speak right to your heart – one report has suggested that 81% of mums experience a mental health problem in the period of pregnancy and new parenthood.
This can range from anxiety, to postnatal depression, and even post traumatic stress disorder. Luckily the conversation is growing, and mums are feeling more able to accept and talk about how pregnancy, childbirth and motherhood really affects them, but there is still a long way to go, and those that experience these sort of issues still feel that there is stigma around discussing their mental health.
We spoke with @mumologist about the emotional and mental challenges that face us as mothers, how to know when and how to ask for help, and some healthy ‘coping mechanisms’ that may be useful for you to try at home when things can feel a bit much.
What challenges do we face as new mums?
For most of us, those early days after birth are a huge shock to the system. I don’t think its an understatement to say that even when birth goes ‘well’, we enter the steepest learning curve of our lives since we were babies ourselves. And in the modern day and age, we often go through this without much support and with a whole heap of pressure.
We also go from having days we can control, often with a fairly regular routine, to finding ourselves at the mercy of a very tiny commander who can’t speak. Day and night lose their meaning. We may have gone from someone who took pride in their appearance to someone who is bleeding copiously, leaking milk everywhere and covered in baby sick. Days that were once spent with other people (at work or socially) are suddenly spent in quiet isolation. And our partners frequently stand on the outside looking in, wondering how they can help but not quite knowing how.
Becoming a mother changes our whole identity – it changes our values, our daily life, our priorities, our bodies, our minds. Remember being a teenager and how high your emotions were? Well, US psychiatrist Alexandra Sachs has suggested that new motherhood should be termed ‘matrescence’ as this is when we are search for a totally new identity, all over again. And all this while being responsible for a very helpless human being?! No wonder it’s hard!
What are baby blues? And how do I know if I’m experiencing these, or something a bit more serious?
It’s usual to feel some ‘baby blues’ when the hormones of birth start to wear off in the week or so after birth. You might feel:
- Low in mood
For some people, the term ‘baby blues’ really doesn’t describe the extent of grief and sadness that hits them in those first few days or weeks. But slowly, as your hormones settle this should pass.
If you feel like you’re not your usual self a month after birth, you may wish to speak to someone about it (see below on ‘Who Should I Speak To…). Equally, if the natural confusion and worry that occur for new parents feels like it’s tipped over into something which affects your actual day to day functioning – it might also be wise to reach out to someone. But how do you know what it is you’re experiencing, when you come to talk to someone?
There are a number of conditions that new parents experience, each of which may require different treatments (whether that is with psychological therapy, or medication, or both).
However it is important to note that, in this period in particular, diagnosis is pretty complicated. For example, half of people with Post Traumatic Stress Disorder after birth will also have symptoms of post natal depression. Those who have experienced high levels of anxiety during birth are more prone to depression after birth too.
Some researchers have suggested that we should actually refer to all mental health problems in this time as ‘perinatal distress’ and move away from diagnosis altogether. The one thing to remember is that, if you are feeling in any way that your daily life is being impacted by your mood or mental health, it is crucial that you seek support as soon as possible. If you have a friend or family member and recognize any of these symptoms too, don’t be afraid to ask them how they are feeling and encourage them to seek help.
Perinatal Depression & Anxiety
Perinatal depression and anxiety are the most common mental health problem affecting 10-15% of women during this period. We also know that about 10% of men may also suffer from postnatal depression, although this is a fairly new area of research and there are lots of questions to be asked about partner’s perinatal mental health, including in same sex relationships which are still under-researched.
Anxiety and depression often overlap, particularly for pregnant and postnatal women. Although we usually think of depression as leading to a flat mood, actually we know that many people who are depressed are in a high state of stress. Both perinatal anxiety and depression can be seen as having similar root causes, which are manifested differently. Some people respond by shutting down, and others by becoming overly vigilant.
What is Perinatal Depression?
To meet a diagnosis for perinatal depression, we would expect to see the following symptoms:
Depressed mood or a loss of interest or pleasure in daily activities consistently for at least a 2 week period, during pregnancy or within first 4 weeks post-partum (although most recognise up to 1 year)
This mood must represent a change from the person’s normal mood.
In addition, the person’s social, family, work, or school functioning must also be negatively impaired by the change in mood.
Usually assessed using Edinburgh Post Natal Depression Scale (10 items)
Changes in mood may not only be seen as feeling low or flat, some people also find that they are more irritable than usual and losing their patience.
Why do some people get depressed?
Some people are more susceptible than others to becoming depressed during this period. Rates of postnatal depression vary quite dramatically around the world, and one of the key differences seems to be the level of support a parent has around them. Parents are also more vulnerable to becoming depressed if they have a history of depression, either during or before pregnant, if they have little support or are at any socioeconomic disadvantage. Understandably, people in physically or emotionally abusive relationships are at increased risk of developing post natal depression. Factors to do with the pregnancy itself can also make us more vulnerable – whether the baby was planned, or whether there was a long journey to becoming pregnant including fertility treatments or pregnancy complications.
There is a strong argument that post natal depression is actually a very normal response to an unusual situation. Women are often parenting in isolation in the modern Western world, and parenthood is no longer valued as a ‘vocation’. The enormous pressure this places on women and couples can have an impact on their mental health.
Psychological Treatments for Depression
The current NICE guidelines for perinatal depression suggest that psychological interventions are effective in this period, particularly Cognitive Behavioural Therapy and interpersonal therapy. These will usually be available via your local IAPT (Improving Access to Psychological Therapies) service, accessed via your GP or often via self-referral. For parents with more severe depression, a referral to a perinatal mental health team or community mental health team may be suggested.
Other treatments, such as counselling and psychodynamic therapy, may also be effective. Peer support is often available for mums, but there is so far little evidence to suggest that this is effective. There is also growing evidence that physical exercise can help to reduce symptoms of depression.
It is now widely accepted that perinatal depression can have long lasting effects on a developing child. There are a number of parent-infant interventions which can support the relationship, often accessed through local Child and Adolescent Mental Health services. These might include positive parenting groups or parent-infant psychological treatments.
It’s important to remember that, while we are particularly vulnerable to mental health problems during this period of our lives, we are also very receptive to treatments. If you are suffering from depression, it is not your fault, and not something you can just ‘snap out of’. It just means you may need a little support in getting through this period of your life.
There is a lot of information and support on the PANDAS website.
About 10-15% of women will experience perinatal anxiety – making it the most common perinatal mental health problem alongside postnatal depression. Often women experience both anxiety and depression together after having a baby. Anxiety might include postnatal generalized anxiety disorder, panic disorder, phobias, postnatal obsessive compulsive disorder, social anxiety and health anxiety.
Symptoms of Anxiety
Anxiety symptoms are usually assessed with the Generalised Anxiety and Depression Scale. Symptoms may be both psychological and physical, including symptoms such as:
|How you might feel physically||How you might feel psychologically|
What links all anxiety disorders is that people often develop ‘safety behaviours’ to cope with their anxiety symptoms, such as only going to trusted places or being with trusted people, not going too far from home or seeking reassurance. For parents this can be particularly hard to spot, as it is common for parents to feel some level of worry. Again, the key is if it is affecting their day to day functioning.
Treatment for Anxiety Disorders
The treatments for anxiety disorders during this period are similar to those outside the perinatal period. Usually Cognitive Behavioural Therapy will be offered, sometimes alongside applied relaxation. Mindfulness-based Stress Reduction is also growing in popularity, although there is not yet strong evidence to support its effectiveness.
Speak to your GP, midwife or Health Visitor to find out what is available in your local area.
You can find information and support at Anxiety UK.
Obsessive Compulsive Disorder
Obsessive Compulsive Disorder (OCD) is a less common anxiety disorder, affecting around 3% of mothers every year. It has similar pathways to other anxiety disorders, but differs in the severity of the thoughts and the meaning placed on them.
Obsessions are defined as “repetitive and intrusive thoughts or images, which may be violent, sexual or blasphemous in nature but also includes feelings of continuous self-doubt, indecision or extreme levels of perfectionism. Obsessions often induce feelings of anxiety, guilt and distress which precipitates the onset of compulsions: repetitive behavioural or mental acts utilised to temporarily relieve this distress. Compulsive behaviours include thinking ‘neutralising’ thoughts repetitively, ritualistic behaviours, continuous checking, reassurance seeking and total avoidance of activities, objects or places associated with the obsession”
However, intrusive thoughts are extremely common in new parents (although don’t usually lead to compulsive behaviours). One study found that 91% of new mothers experience some unwanted intrusive thoughts during new motherhood, alongside 88% of new fathers. These are often related to childbirth experiences.
Although referred to as Obsessive Compulsive disorder, it is not always necessary to have both obsessions and compulsions in order to be diagnosed. In fact, postnatal women are more likely to have obsessive thoughts rather than compulsive behaviours. These are often around the baby, such as thoughts of accidents, of losing the baby, worries about hygiene and ideas about causing harm to the baby. Common compulsions in new parents are compulsive checking (e.g. repeatedly checking the baby is still breathing) and compulsive cleaning (repeatedly cleaning toys, sterilizing bottles etc)
Treatment for OCD
Just as with other anxiety disorders, OCD is most commonly treated with Cognitive Behavioural Therapy. This may include Exposure therapy. This can usually be accessed via your GP.
You can find a lot of information and support at Maternal OCD.
Post Traumatic Stress Disorder after Birth
There is a growing awareness that many women and their partners can feel traumatised after a birth. We think that 1-3% of women suffer PTSD after birth, although many more (around 20-30%) will have symptoms of trauma without meeting the diagnostic criteria for PTSD.
PTSD is defined as a reaction to a particular traumatic stressor – either directly, through witnessing the trauma or even through hearing about a traumatic event. In this case, this might include a birth partner, health care professionals, or the birthing woman’s wider network. To meet criteria for a diagnosis, someone will be experiencing:
- at least one symptom of ‘intrusion’ (such as nightmares, flashbacks, feeling distressed at reminders of the event);
- at least one symptom of avoidance (such as avoiding returning to hospital, or avoiding thinking about the event – for some this might include avoiding their baby too);
- at least two symptoms of changes to thoughts and mood(such as feeling flat in mood, or finding it hard to remember aspects of the event) and
- At least two symptoms of changes to responses to situations (such as startling very easily, feeling very irritable or being overly vigilant).
- They will experience these symptoms for over a month
- These symptoms must be affecting their day to day functioning
- These symptoms are not due to medication, substance abuse or other illness.
Many people may experience some or all of these symptoms soon after a traumatic event but most will find that they resolve alone over time, as the individual processes what has happened to them. If you are still experiencing these symptoms over a month after your birth, then it is time to seek support. For many women and their partners, however, it is often months or even years later that they realise their symptoms are out of the ordinary. The business of looking after a baby means that you often do not acknowledge how they have been feeling until they have settled into your parenting role.
Many also experience some but not all of these symptoms, but will still benefit from support.
Psychological Treatments for Birth Trauma
The NICE guidelines currently recommend that treatments of choice are Trauma Focused Cognitive Behavioural Therapy or Eye Movement Desensitization and Reprocessing therapy. Both of these require specialist training and supervision. They are based on reprocessing the traumatic memories so that they can be ‘refiled’ alongside other long term memories, letting you know that they are safe again.
Parents also find other treatments can be helpful after a traumatic birth. Body therapies such as massage (including Closing the Bones ceremonies) or yoga can be very beneficial for some women. However, these are not yet grounded in an evidence base.
There are a growing number of other treatments for birth trauma. It is important to remember that, if you have been traumatised by your birth, memory-focused treatments do put you at some risk of being re-traumatised. You should always check that whoever you are working with has experience of working with trauma and has appropriate supervision.
Other Mental Health Problems
You might find that something else is affecting you during this time.
Although eating disorders are actually less prevalent in pregnant and postpartum women than in the general population, some women do develop eating disorders during this period or may relapse from a previous eating disorder. Pregnancy can be a very anxious time if you have a history of eating problems, as you see your body changing. For some people, this results in a relapse after birth. This may create additional problems around feeding and weaning of the baby, which creates a vicious cycle increasing your levels of anxiety.
If you feel that you are struggling with an eating disorder, it is really important that you seek help quickly. See BEAT for support and information.
Psychotic Disorders (Psychosis and Bipolar Disorder)
Postpartum psychosis is very unusual, affecting only 0.1% of women after birth, but if left untreated can have an enormous impact on people’s lives. Symptoms include hallucinations, delusions, feeling manic (feeling ‘high’ or ‘on top of the world’), restlessness, confusion and generally behaving out of character. Bipolar disorder, although a separate diagnosis, is very linked to postpartum psychosis. With bipolar disorder, you might find that your mood cycles between periods of severe depression and periods of mania. Women are particualrly vulnerable to developing or relapsing with bipolar disorder in this period. Lack of sleep can worsen these disorders very rapidly. If you do think you might be experiencing an episode of psychosis or mania, or you are worried about someone, it is important that you seek help urgently.
Action on Postpartum Psychosis is a brilliant resource, which also offers support to partners.
Suicide and Risk
Sometimes your mood becomes so low during this period that you might think about harming yourself or your baby. These thoughts can be very frightening, and you might not wish to speak to anyone about them for fear of what might happen. However, if you are having thoughts like this, it is really important that you speak to someone about them. People may go through very dark periods and still recover fully with the right support. Healthcare professionals are trained to help you at times like this, so please do speak to someone as soon as you can. This might be a GP, midwife or Health Visitor, or you might want to confide in a friend or family member who can then support you in speaking to a healthcare professional. You can also call the Samaritans at any time, day or night. If you are really worried about your state of mind, you can also ask your GP for an emergency appointment, or go to A&E.
Who should I/can I speak to?
Friends/Family – sometimes it can feel really difficult bringing up such a sensitive subject. But often, the people around you can see that you’re not quite yourself and are probably wondering how to raise it themselves. Don’t wait to be asked. Let them know how you’re feeling and don’t be afraid to ask for their support. It’s likely they’ve been through something similar at some point. Occasionally, you might find someone who isn’t receptive to hearing about your feelings. Often, that’s more to do with them than you, so hurtful as it is look for someone you might find more supportive.
GP, midwife, health visitor – while healthcare professionals should ask you about your mood, often you might not feel able to go into it in detail because appointments are time pressured. It’s useful to ask for a double appointment with the GP, or to let your midwife or health visitor know that you need to speak to them about your mental health so that they allocate time. Many healthcare professionals have specialist training in maternal mental health.
If you don’t feel like you’re getting anywhere with your GP, don’t be afraid to book an appointment with a different GP who might have more knowledge of mental health. Or you can also often refer yourself to a primary care psychology or counselling service (look up IAPT in your area) or ask to speak to a specialist mental health midwife.
You can also look for a local psychologist or counsellor – many specialise in helping parents through this time. The British Psychological Society has a ‘find a psychologist’ page, and the Make Birth Better website has a growing map of individuals and services supporting families after birth.
There are also many supportive online communities, have a look at www.pandasfoundation.org.uk.
Some people really worry about raising their mood with anyone. This might be because they fear what the response will be, but also once a baby comes along people worry about Social Services involvement. It’s worth knowing that this is a very vulnerable time for women and, without support, mental health problems can get worse sometimes quite quickly. Most of the time, you will find that what you are going through is not unusual – often what feels catastrophic to us is not uncommon to the healthcare professionals you are working with. However, occasionally people need support in looking after their child. We hear a lot of horror stories about Social Services, but Social Workers are there to help you as a family and their involvement can often be extremely useful. They are often brilliant at helping you access all of the different types of support you might need.
What are some healthy coping mechanisms that might help me at home?
Prioritise sleep: There’s that old phrase ‘sleep when the baby sleeps’ which many new mums find very irritating! When the baby sleeps (if it sleeps) can feel like a precious time to get things done and just spend a bit of time alone. However, sleep is so linked to mood and catching up where you can will really help you feel more stable. Sleep should be your number one priority!
Be KIND to yourself: remember, if you started a new job, you’d give yourself a good few weeks to settle in. But somehow we expect that we will just ‘know’ how to be a mother. You’ve just been introduced to a total stranger, who can’t tell you what they need, and you’re still reeling yourself. Give yourself a few MONTHS to land on your feet again. If you expect that it’ll all feel new, and strange, sometimes wonderful, sometimes awful, then you’ll be able to ride the wave with kindness not judgement.
Choose your advisers carefully. People love to give advice on parenting, and this is always influenced by their own parenting choices. They may not be your parenting choices, and that’s ok. You need to give yourself time to find your own way. Listen to the advice you like, read the books which resonate with you, and to all the rest say ‘thanks for your advice’ then completely ignore it.
Find your balance: You may feel like you really miss your old self in the early weeks and months of becoming a mother. Again, this is so normal and to be expected. But we can react to these changes to our identity in one of two ways – rushing back to ‘normality’ too soon or completely submerging yourself in your motherhood. If we try and rush back to normal, the risk is that we’ll end up exhausted and resentful at the changes which are occurring. If we submerge ourselves completely, putting our children’s needs first all the time….well we’ll also end up burnt out and resentful. Think about where the balance lies for you. What of your ‘old life’ do you most miss, and is there any way of introducing that into your mothering life? It may be as simple as asking a friend or your partner to look after the baby on a Saturday morning so you can go for a walk and a coffee on your own…
Talk to your partner if you have one: Especially when partners go back to work, women can feel that they shoulder most of the responsibility for looking after children – and also running a household. It’s really important therefore to talk to your partner about how you’re feeling about the responsibilities you both have. Having young children puts an enormous strain on relationships, and talking about how you are both weathering the transition can help to alleviate that strain. If you feel like you need a third party to help you with this conversation, there are many organisations out there to help. Relate offer specialist support for parents, take a look at their website for lots of helpful information.
Work out what works for YOU: There’s a lot out there about self-care for mothers, and making sure you’re getting ‘me-time’. But self-care is different for everyone. Above all else, it helps to prioritise your sleep and your nutrition. Massages and yoga classes won’t make much difference if you’re exhausted. You might find that you’re happy to leave your baby with someone else while you take some time out – but equally you may feel that you have no desire to spend time without them. It’s helpful to remember that there is no ‘normal’, just what is normal for you. Allow yourself time – and then more time – to find out what is helpful to you and for your family.
Some other things that may help…
- Exercise: just being outside, and going for a 15-20 minute walk with baby every day for 15-20 minutes can be enough to give you a boost. Plus it gives us a good dose of Vitamin D which is often deficient post birth
- Nourishing diet: it can be really hard post birth to cook meals that are nourhsing for your mind, body and soul. If you can, ask friends to cook you something hearty instead of bringing the baby gifts. Avoid sugar and too much caffeine, as these will give you energy crashes. Stay well hydrated too.
- Magnesium can really help anxiety post birth. Have a cupful of Epsom salts in the bath or take supplement, 300-600 mg per day.
- Meditation: apps like Calm, Headspace, Buddify, Happy Not Perfect and Clementine all offer quick ‘time out’ breathing practices that can work wonders on calming the nervous system.
- Have a read: there are some great books out there now for new mums. ‘How to Heal a Bad Birth’, ‘The Fourth Trimester’, ‘The Supermum Myth’ and ‘Fine not Fine’.
- Dip into your social networks and remind yourself you’re not alone. Mush Mums, Peanut, your local NCT group, and even babies’ playgroups. Remember – we are all in this together, we are a ‘tribe’ of mummies!
Dr Emma Svanberg is a Clinical Psychologist specialising in supporting women and their partners through pregnancy, birth and the early years. She works in private practice in North London, and also runs a local group – The Village – to offer parents a safe space to discuss the ups and downs of their parenting journey. Emma also co-founded the Make Birth Better Network alongside perinatal psychiatrist Dr Rebecca Moore, to raise awareness of birth trauma and campaign for increased awareness in maternity services. Most important, she is a mum of two.