By Kimberly Evans, MD, reproductive psychiatrist at CHRISTUS in San Antonio
Every year on May 1, clinicians worldwide observe World Maternal Mental Health Day to spread awareness about mental health challenges faced by pregnant and postpartum individuals, including perinatal mood and anxiety disorders (PMADs), which frequently go unrecognized and untreated.
PMADs encompass a range of mental health issues affecting people during pregnancy and the first year after delivery. These conditions include Major Depressive Disorder, bipolar disorder and a range of anxiety disorders. Approximately 15 to 20% of new mothers will have some form of PMADs during this period.
This differs from "baby blues," which affects roughly 70% of women. Unlike baby blues, which resolves within those first two weeks and includes symptoms like mood swings, tearfulness, irritability, and anxiety, PMADs are more severe and enduring.
While it’s normal for parents to worry about their baby, excessive worry that disrupts sleep or daily activities is not normal. Signs of postpartum anxiety include waking frequently out of fear that your baby has stopped breathing, persistent intrusive thoughts about harming your baby, severe appetite changes, irritability, and constant worry that takes up more than an hour of your day or keeps you from caring for yourself or your baby.
While occasional tears due to stress or exhaustion are normal, having frequent crying spells, persistent feelings of numbness, or an inability to enjoy activities you once did may indicate depression. If you recognize these signs in yourself or someone else, consult a health care provider for an evaluation, as these symptoms require intervention to prevent them from worsening.
Several factors can increase a person’s risk for PMADs. In my clinic, I talk about how manageable stress levels during pregnancy are normal and not harmful to the mother or baby, but persistent or intense stress can lead to several complications, including premature birth, low birth weight, preeclampsia, gestational diabetes, and increased likelihood of cesarean delivery.
Even more, experiencing depression or anxiety during pregnancy is a major predictor of postpartum depression or anxiety. Thankfully, successful management of mental health during pregnancy can significantly reduce the risk of PMADs.
Stress immediately after birth is another factor that increases a person’s risk for PMADs. Complications during delivery or a baby’s admission to the NICU have been associated with risk for postpartum depression and anxiety.
Unfortunately, we are seeing more and more cases of PMADs in our clinic, an observation that corresponds with data collected across the U.S. In fact, the Centers for Disease Control and Prevention (CDC) found that the rate of postpartum depression increased sevenfold between 2000 and 2015.
In Texas, a 2013 study highlighted mental health disorders as one of the leading causes of maternal deaths in the first year postpartum, tying with cardiovascular conditions at 13% for the most common causes.
Moreover, between 2008 and 2019, 8.8% of suicides among U.S. women of reproductive age occurred in those who were pregnant or recently postpartum. These startling statistics underscore the critical impact of mental health on maternal mortality and the consequences of untreated mental health issues.
Recognizing a crucial coverage gap, Texas has recently taken significant steps to support new mothers. The state extended Medicaid and Children’s Health Insurance Program eligibility from 60 days to 12 months postpartum, effective March 1, 2024.
The goal of this extension through the Texas Health and Human Services Commission is to ensure that women have necessary health coverage during the most vulnerable period of their lives, substantially improving access to mental health services.
As a psychiatrist, I applaud this change, especially since pregnancy and the immediate postpartum period are sometimes the only opportunities for low-income women to access insured medical care, including mental health support.
To improve maternal health outcomes, we must prioritize and improve our screening processes to detect mental health concerns as early as possible. The American College of Obstetricians and Gynecologists recommends screening for mood and anxiety disorders at least once during the perinatal period.
The American Academy of Pediatrics has also recommended that pediatricians screen mothers during infant appointments at one, two, four, and six months, because these checkups may be the only time postpartum women see a health care professional in the immediate months after their child’s birth.
The primary tool used for this is the Edinburgh Postnatal Depression Scale which is widely validated for assessing postpartum depression. Additionally, other valuable tools we use include the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Questionnaire (GAD-7), which help identify patients at risk of depression and anxiety during the prenatal period, allowing for early intervention.
In our Maternal Fetal Medicine - Perinatal Mental Health Clinic at CHRISTUS Children’s, we routinely use these screening tools. Patients identified as high-risk are referred to psychiatrists like me or another mental health professional on our team.
This proactive approach aims to improve health outcomes for both mothers and babies by identifying appropriate treatment, which could include medication, therapy, and behavioral interventions.
In treating pregnant and postpartum patients, therapy plays a crucial role alongside medication. We focus on connecting patients with counselors or therapists who can help them manage stress and adjust to the many life changes accompanying parenthood. This is vital, especially for those with pre-existing mental health conditions.
Another key aspect of treatment is behavioral interventions. Not all patients are comfortable with medication, and many may prefer non-pharmacological options.
One of the most important tools I talk about with my patients is sleep management due to its immense health benefits. We often advise on sleep consolidation techniques to maximize rest, when possible, an approach that might involve shift-sharing between caregivers to allow longer, uninterrupted sleep periods. This is particularly important when dealing with the physical recovery of childbirth and for some, breastfeeding.
Proper nutrition is another focus. I am constantly reminding new parents about the importance of consuming sufficient calories and staying hydrated.
Additionally, self-care routines are essential. Simple activities like taking a shower, stepping outside, or even brief separations from the baby can significantly reduce stress. Understanding that it’s safe to let a baby cry momentarily in a secure setting allows parents to take necessary breaks and manage their well-being.
These strategies, from psychological support to practical behavioral adjustments, form the backbone of our therapeutic approach as we help new parents navigate the complex physical and emotional landscape of the postpartum period.
Since our Maternal Fetal Medicine - Perinatal Mental Health Clinic was launched at CHRISTUS in 2023, we have seen significant patient engagement. By the end of February 2024, the clinic had recorded 480 psychiatry patient encounters.
The majority of these patients were diagnosed with Major Depressive Disorder and Anxiety disorders, which together represent approximately 43% of the total diagnoses we have seen.
This data underscores the critical need for such specialized mental health services in the perinatal period. The high prevalence of these conditions highlights the role of timely and effective mental health care, which our clinic strives to provide.
Recognizing the importance of mental health during and after pregnancy is essential, not just on this observance day but every day. Our commitment at CHRISTUS is to continue improving and expanding our services to meet the needs of expecting and new mothers, ensuring they receive the support they deserve during this pivotal time in their lives.
To learn more about Medicaid and CHIP postpartum coverage, visit the HHSC's Women and Children webpage. To apply for Medicaid or CHIP, call 2-1-1 and choose Option 2 or visit YourTexasBenefits.com.
