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Postpartum Anxiety Might Be More Common Than Depression, & The System Keeps Missing It

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About five months after giving birth, Lauren Cecora began to struggle with what she described as postpartum “anxiety spirals.” The California mom tells Romper, “Worst-case scenarios began to play out in my head. I had just returned to my fast-paced job, and my biggest fear was that I suddenly wasn’t keeping up. The thought of being fired raced over and over in my mind. I’d basically work myself into such a frenzy that I couldn’t sleep when nighttime rolled around. I was an anxious mess.”

Postpartum anxiety may actually be far more common that postpartum depression, but postpartum depression is the more talked-about condition.

A few months earlier, at her four-week post-birth checkup, Lauren had been diagnosed with postpartum depression (PPD). Her husband had deployed when she was 28 weeks pregnant, and she didn’t have much in the way of nearby family support.

But what was actually going on was something different entirely. The only problem was Cecora didn’t know what.

What Cecora began to experience after returning to work was postpartum anxiety (PPA). A 2016 study in the Journal of Affective Disorders found that PPA may actually be far more common that PPD, but PPD is the more talked-about condition.

Maranda Davis had experienced anxiety prior to having children, but says the PPA was something she couldn't rationalize away. Photo courtesy of Maranda Davis.

Licensed Professional Counselor Kristen Treat explains to Romper, “In my own practice, I do see slightly more women with postpartum anxiety than depression. And within postpartum anxiety, you also have the areas of postpartum obsessive disorder and postpartum panic disorder.”

Yes, there is more within the PPA family that most people have probably never heard of. A 2009 study in The Journal of Reproductive Medicine found that 11 percent of women screened positive for obsessive-compulsive disorder symptoms two weeks after giving birth, with almost half of those women continuing to experience persistent symptoms at six months postpartum.

So why is it that we only seem to be talking about PPD? And is it even possible for those suffering from PPA (or one of the offshoots of PPA) to get the care they need when there seems to be so little known about these conditions?

In my practice, I see more PPA than PPD, but most women come in calling it depression.

Licensed Mental Health Counselor Nicky Treadway tells Romper, “People often lump PPA and PPD into one category and actually just call it ‘postpartum.’ The problem is that anyone who has ever given birth experiences a postpartum phase, so it’s really important that we use accurate language so we can treat individuals. In my practice, I see more PPA than PPD, but most women come in calling it depression.”

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Recognizing the difference between these two conditions is half the battle. Dr. Poppy, an M.D in obstetrics and gynecology, tells Romper, “Most people are familiar with depression being a down mood: blue, sad, crying, emotional, that kind of thing. PPA is different. People don’t necessarily feel sad, but they can feel anxious and stressed. It’s often hard for new moms to know what’s normal. Especially since most area also sleep-deprived. PPA can go unrecognized and be pinned down as normal for a long time.”

Treadway explained that in her practice, differentiating between PPA and PPD often comes down to how her patients behave in front of her. “The women with PPA usually can’t sit still,” she tells me. “They bounce and move and their anxiety is pouring out of them.”

All my mind would do was go to scary scenarios of my kids being hurt with me having to watch, unable to save them. I would make up plans for how I could try to save them.

That was Oregon mom Ali Nichelson’s experience. “I had a hard time falling asleep,” she tells Romper. “When I would try to slow down, all my mind would do was go to scary scenarios of my kids being hurt with me having to watch, unable to save them. I would make up plans for how I could try to save them. My imagination took off and I thought of everything imaginable, like what I would do if someone broke into our house and threw one of our sons from the second-story window. I had a few options, and I’d run through them and try to figure out which would be the best in order to get to him fastest.”

Ali Nicholson and then-4-month-old son. Photo courtesy of Ali Nicholson

According to Nichelson, her life became moment-to-moment, always full of stress. “My work suffered, my parenting suffered, and my friendships had to be put on hold because I just couldn’t handle one more thing to think about.”

It took months for her to receive the help she needed. “My baby was around a year old before I was finally on medication,” she says. This was despite the fact that her therapist later concluded she had likely started suffering from anxiety during pregnancy. “I lost a pregnancy before I conceived my son and it was devastating. I spent most of my pregnancy scared something would go wrong, waiting for it. When I cried in relief at my 36-week appointment, my OB asked me if I’d been holding my breath the whole pregnancy.”

It’s fair for one to wonder why it then took so long for Nichelson to receive a diagnosis and help. After all, if she had begun exhibiting symptoms so early on, why wasn’t this something her medical care practitioners were following up on?

Treat tells Romper, “Postpartum Support International advocated for universal screening at various time periods via the Edinburgh Postnatal Depression Screen (EPDS). But currently, not all OB-GYNs and midwives follow through with that screening.”

There is another problem as well. Treadway explains, “The Edinburgh is specifically [a] screening for depression,” which means that patients experiencing PPA may be missed entirely. “There is also a Postpartum Distress Measure,” Treadway goes on. “It isn’t validated, but it is used by some in the maternal mental health field to assess for PPA. And then there is the GAD 7, which is a Generalized Anxiety Disorder screening. That’s not specific to women during pregnancy or after giving birth, though.”

I have a policy in my office that I see all of my patients at one week, even if they delivered vaginally. Those patients don’t typically see a doctor until six weeks, which is a bad idea in my opinion.

She sighs then adds, “Screening is an area we could definitely improve upon.”

In Dr. Poppy’s practice, she’s found that being proactive is key. “I have a policy in my office that I see all of my patients at one week, even if they delivered vaginally. Those patients don’t typically see a doctor until six weeks, which is a bad idea in my opinion. You can catch a lot in that first week if you see them.”

All three health professionals Romper spoke to pointed out that a family history of anxiety, or experiencing anxiety prior to (or during) pregnancy were all risk factors for an increased likelihood of experiencing PPA. These are the patients doctors should probably be paying closer attention to.

Maranda Davis fell into that category. “I had always struggled with some level of anxiety, though I had never been officially diagnosed or treated,” she tells Romper. “Before giving birth, I was able to talk myself out of my anxious episodes. I could separate my logical self from my anxious self. But when PPA started, I could no longer rationalize my feelings away. The day I called my midwife, I had locked myself and my kids in our bathroom at home because I was so afraid of a tree falling on our house. I just held all three of them and bawled.”

Luckily, Davis was able to get help quickly. “I think I waited two to three weeks from the first signs before calling. My midwife’s office was amazing. I called them around 4 p.m. and when I described my symptoms, the scheduler immediately transferred me to their triage nurse who discussed my concerns and was able to get me in for an appointment the very next morning.”

Maranda Davis was able to get help quickly. Photo courtesy of Maranda Davis.

Unfortunately, not all women are as lucky.

“I was in denial for six to eight weeks after it started,” Cecora tells Romper. “I kept telling myself I was fine, that this was normal for back-to-work stress and dealing with re-integration after my husband returned from deployment. It wasn’t until I had a breakdown in front of my husband that he insisted this wasn’t normal.”

From there, she struggled to find the help she needed. “PPA resources were few and far between. I’d gone back to my counselor with my husband, and we both did talk therapy, but we essentially had to come up with our own plan. Googling, trial and error, taking charge, finding other people who had been experiencing the same thing; my treatment plan was basically created from scratch. I don’t recommend that. It was really hard, and it took about a year before I started to feel normal again.”

Dr. Poppy tries to dive deep with her patients. “I find that a lot of the issues I see are hormonal, so I do a lot of hormonal support,” she says. And a part of her inquiry has to do with assessing the mother’s situation. “Maybe they don’t have a lot of friends, or they don’t have experience with babies. Maybe they are having trouble with breastfeeding, and all of that is being compounded by sleep deprivation. And maybe medication is what is needed to get them feeling on track again. Every patient is different in what they need,” she says.

If universal screening tools were used by OB-GYNs and midwives at periodic times during a woman’s prenatal care, as well as at pediatrician’s offices during well-baby checks, we’d probably find a lot more women getting the help they need.

Unfortunately, not all healthcare professionals are willing to make that kind of commitment to their patients. And of those who may be willing, not all over the training and experience necessary to provide that more individualized treatment plan.

“It would be helpful if every provider who can catch a baby was also skilled in what to look for in regards to PPA and PPD,” Treat says. “If universal screening tools were used by OB-GYNs and midwives at periodic times during a woman’s prenatal care, as well as at pediatrician’s offices during well-baby checks, we’d probably find a lot more women getting the help they need. It would also be helpful if every office had a clear referral protocol on what to do when moms do screen higher or report needing help. This isn’t always the case.”

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Treadway had other ideas for how we can improve outcomes for women suffering from PPA. “I think mental health in general is hard to talk about and hard for people to discuss. I work really hard to normalize mental health in my personal and professional life, so that ‘I went to therapy’ becomes as natural to say as ‘I got a massage’ or ‘I went to the doctor.’”

Cecora agrees, and it’s why she now volunteers with the same organization that eventually helped her find the help she needed. “At first, only my in-laws and my boss knew. My boss, because I had to have my disability extended. And my in-laws because my father-in-law happened to be at an appointment with me when it was mentioned. If it had been my choice, they never would have known. While I was going through it, I was so afraid to talk about what I was thinking and feeling for fear that someone would try to take my daughter way. I can talk about it now because I’ve had counseling and I understand the dark thoughts I was having were anxiety. But then? It was really scary.”

Cecora also admits that it was returning to work when her baby was only 4-and-a-half months old that really ignited the PPA symptoms for her. And in a country that ranks last among 41 nations for paid parental leave (according to the Pew Research Center) it’s certainly fair to argue that returning to work too soon could be a contributing factor to PPA for other women as well (though that research does not exist as of yet.)

Being an insurance-driven model, people tend to operate based on what insurance will pay for and what clients can pay out of pocket.

Treadway identified some other societal issues that could be contributing to PPA. “There is a lack of integrated care in the U.S.,” she says. “You hear that term a lot, the integrative care model, where professionals are working together. And it’s this really beautiful idea, but it’s also really hard to do because that means practitioners have to work together and spend time outside their existing job duties and talk to other people and work on existing care. Being an insurance-driven model, people tend to operate based on what insurance will pay for and what clients can pay out of pocket. We tend to be driven by those factors, instead of trying to break that barrier and really meet the needs of clients.”

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There are no perfect answers right now, but all the individuals Romper spoke to for this article agreed that the U.S. healthcare system is currently failing to properly screen and treat these women.

Perhaps combatting that starts with talking about it, both in terms of raising awareness and reaching out for help when any of us are struggling.

“I think it’s important for people to know that even if they are afraid, they have to tell somebody.” Cecora says. “You need to find somebody that you feel safe with and tell them how you’re feeling and that you need help but you don’t know how to find it. In order for things to change and to get help, we have to tell someone.”

So if you or someone you love is suffering from what you suspect may be PPA or PPD, tell someone. Until we have a better system in place, we'll have follow the sound of our own voices.

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