This course will be updated or discontinued on or before Saturday, May 8, 2027
Nationally Accredited
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
Outcomes
≥ 92% of participants will know how to recognize postpartum depression and anxiety.
Objectives
After completing this continuing education course, the participant will be able to:
Define terminology related to the perinatal period.
Identify the signs and symptoms of postpartum depression and anxiety.
Determine the screening tools that can be utilized for identifying potential postpartum depression and anxiety.
Outline the recommended treatment options for postpartum depression and anxiety.
Differentiate postpartum obsessive-compulsive disorder (OCD) from postpartum psychosis.
Explain the nurse’s role in caring for postpartum mothers with or at risk for perinatal mood and anxiety disorders (PMADs).
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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Nursing Assistants from California, only. You must read the material on this page before you can take the test. The California Department of Public Health, Training Program Review Unit has determined that is the only way to prove that you actually spent the time to read the course. Less
The perinatal period can be defined as the time from when a baby is conceived and continues through the entire first year after the child is born (Postpartum Support International [PSI], 2025).
This definition of the perinatal period takes into account the significant fluctuations in hormones during the full course of pregnancy, birth, immediately following birth, the initiation of lactation, cessation of lactation, and the re-initiation of menstruation postpartum (PSI, 2025).
The postpartum period, while included in the full perinatal period, is defined as the time frame from birth until the child’s first birthday (PSI, 2025).
It is important to note here that although the default descriptive term that will be utilized throughout this course is “woman” or “mother”, it is not meant to exclude any individual or any term someone prefers or identifies with. All birthing individuals, gestational carriers, and surrogates are meant to be included.
D: Disorders (impacting and interfering with daily functioning)
This name shift better acknowledges a broader range of mood and anxiety disorders, as well as brings awareness to the fact that any of these disorders can occur during pregnancy in addition to the postpartum period (PSI, 2025).
While all included disorders within PMADs are extremely important to identify and treat, and the time frame is inclusive of the pregnancy period as well, this course will focus specifically on the postpartum period and include a thorough review of postpartum depression and postpartum anxiety.
Risk factors increase the chance of someone having a particular issue. There are several risk factors for PMADs during the postpartum period, including (American Psychological Association [APA], 2023; PSI, 2025; Amer et al., 2024; Felton, 2024):
Previous personal experience with depression and/or anxiety
Family history of depression and/or anxiety
Personal or family history of other psychiatric disorders
Infertility issues
History of miscarriage/prenatal loss
Experiencing high-stress life events
Unplanned or unwanted pregnancy
Lack of support from family and friends
Childcare stressors
Interpersonal violence (IPV)
History of trauma or adverse life events
Physical changes related to pregnancy
Having an infant in the neonatal intensive care unit (NICU)
Medical complications for the mother during pregnancy, birth, or breastfeeding
Being an adolescent mother
Being a military spouse
Changes in close relationships
Work-related issues (such as having to return to work early or against one's wishes)
Financial stressors
Unresolved grief or loss
Temperament of the child
Lack of sleep
Hormonal shifts after giving birth
Societal pressure to be “the perfect mom”
Type “A” personality type (ambitious, focused, competitive, highly organized)
According to Postpartum Support International (PSI) (2025), a sensitivity to hormonal changes has been heavily implicated in the cause or increased risk of PMADs. In addition to the estrogen, progesterone, oxytocin, and prolactin that are involved in pregnancy, birth, and immediately after birth, endocrine dysfunction issues such as diabetes, fertility issues, thyroid problems, puberty, premenstrual syndrome (PMS), polycystic ovary syndrome (PCOS), and premenstrual dysphoric disorder (PMDD) have also been associated with an increased risk for PMADs (PSI, 2025).
It has also been noted in the research that psychosocial issues like a woman’s relationship with her own mother, more elevated concerns about entering motherhood, personal issues with perfectionism, structural racism that is personally experienced, and even a history of childhood sexual abuse can predispose a woman to PMADs (PSI, 2025).
As briefly noted above in the list of risk factors, a lack of sleep and poor sleep quality are some of the most significant risk factors for PMADs (PSI, 2025). While sleep deprivation is a normal, expected component of having a newborn, it is important to note that with lack of sleep being one of the biggest contributing factors, for those who are already at an increased risk for PMADs before giving birth, that attention has to be given to this, and mom needs to be given an opportunity to sleep as often as realistically possible. Whether that means having family members support, or a nanny, or a doula, it can be so protective and restorative just to have a solid couple of hours of uninterrupted sleep.
While PMADs have a clear impact on the mother, PMADs also very much affect the child and the family unit. The potential effects of untreated PMADs can include (Tabi et al., 2022; PSI, 2025):
Child abuse
Child neglect
Developmental delays
Behavioral problems
Infanticide, homicide, suicide
Early discontinuation of breastfeeding
Family dysfunction
Intimate partner violence (IPV)
Divorce/separation of caregivers
Loss of financial resources for the care of the child
It is also important to note that children of mothers with undiagnosed or untreated PMADs are at an increased risk for emotional, cognitive, developmental, and even verbal deficits as well as impaired social skills (APA, 2023).
Because pregnant women and their new children are so active within the healthcare system right after birth, we have the opportunity as healthcare professionals to keep an eye out for these conditions each time we see them. While universal screening would be the most ideal for all mothers and it is highly recommended by multiple professional organizations, it is not always done.
There is so much public assumption that obstetrical and gynecological providers (OBGYNs) are the ones who should do all of the screening for postpartum mental health disorders. However, OBGYNs themselves typically do not believe that they are most responsible for doing this.
Why might providers have concerns about screening for postpartum depression?
Some concerns that are brought up by healthcare providers in why they might not administer a screening can include simply not knowing which screening tools to use, their own perception that it will be time-consuming to screen, that they will not know what to do with a positive result, that they might not be getting reimbursed for their time spent administering the screening, and a worry of medical liability if a woman with a positive screening is not treated in a certain way (PSI, 2025).
While these can be valid concerns, education about what tools are best and what to do or how to refer these mothers can help significantly in reducing barriers to screening to identify more mothers suffering from postpartum mental health disorders.
We know that when mothers are screened, it can help us identify those who are more at risk and require additional evaluation, potentially reduce the overall prevalence of depression, shorten the period of time from symptoms to diagnosis, and hopefully, treatment.
So, if OBGYNs are not the only ones who carry some responsibility for screening postpartum mothers, who is? In fact, ALL healthcare professionals who have contact with postpartum mothers and their significant others have the opportunity to screen. This includes lactation counselors, doulas, midwives, therapists, pharmacists, pediatricians, nurses, and even the mother’s primary care provider (PSI, 2025).
While there is no set consensus about *when* screening should occur, the Annals of Family Medicine recommends it at 6 and 12 months postpartum (PSI, 2025). The American College of Obstetricians and Gynecologists (ACOG) recommends screening the mother at least once during the perinatal period (conception to one year postpartum). Also, the AAP recommends screening the mother at their child’s 1-, 2-, 4-, and 6-month well-child visits (PSI, 2025). Generally, PSI recommends that screening should be done at the 6-week postpartum visit (or at the first visit if sooner), at 6 and 12 months postpartum in the OBGYN or primary care settings, and at the 3-, 9-, and 12-month pediatric visits for the child (PSI, 2025).
A few important things to remember when administering a screening are to allow for privacy for it to be completed and to be understanding of literacy differences among mothers, should it be more helpful to administer the screening verbally rather than in writing (PSI, 2025). Also, remember, screening tools are just that, screening tools. They are not meant to be diagnostic, and they are not meant to be a substitute for clinical judgment (PSI, 2025).
An estimated 60-85% of mothers experience what is known as the “baby blues” (PSI, 2025). The “baby blues” is a short-lasting change of condition that generally lasts between 2 days and up to 2 weeks (PSI, 2025; Hantsoo, 2025). This change typically peaks at about 3 to 5 days post-delivery of the child (PSI, 2025). It is said to be due to the intense hormonal fluctuation that occurs at birth, coupled with an acute sleep deprivation (PSI, 2025). The symptoms of the “baby blues” generally include (APA, 2023; PSI, 2025):
Crying all of a sudden, for no specific reason
Restlessness
Anxiety
Irritability
Reactivity
Exhaustion
These symptoms are known to generally resolve on their own, without treatment, and not interfere significantly with the daily activities of caring for a new baby (PSI, 2025; APA, 2023). The mother appears to be relatively happy overall, and her self-esteem is generally intact (PSI, 2025). It is quite typical for a mother to feel happy one minute and then be crying and feeling overwhelmed the next (Hantsoo, 2025). The key component of the “baby blues” is that it is mild and temporary.
How do you know if the “baby blues” is just that or if it is depression?
The major tell-tale signs that help you differentiate between “baby blues” and postpartum depression are based on the symptoms’ severity, timing of onset, and how long these symptoms last (PSI, 2025). If symptoms are significant, affecting and interfering with daily life, and starting and/or persisting AFTER 2 weeks postpartum, this is no longer what we would consider the “baby blues” (PSI, 2025).
So, as we have just learned, “baby blues” is NOT the same thing as postpartum depression. Let’s take a deep dive into the most important things to know about postpartum depression.
The American Academy of Pediatrics (AAP) estimates that about 400,000 infants are born to mothers who are or who become depressed (Joy, 2023). In fact, postpartum depression affects approximately 10-15% of mothers (Amer et al., 2024). That makes it pretty common.
According to a nationwide sample, the prevalence of postpartum depression is higher among American Indians or Alaska Natives (22%), Pacific Islanders or Asians (19%), or Blacks (18%), when compared to White people (11%) (Haight et al., 2024).
Keep in mind that these numbers are based on actually diagnosed postpartum depression. The approximation of how many women who experience postpartum depression that is undiagnosed is said to be as much as 50% (Amer et al., 2024). That is a staggering statistic. Postpartum depression is extremely prevalent.
The signs and symptoms of postpartum depression are generally the same as those of major unipolar depression. Mothers suffering from depression may experience (APA, 2022; Rothschild, 2024):
Low, depressed mood
Low energy
Loss of interest in most activities (anhedonia)
Poor concentration
Change in appetite (eating more or eating less than usual)
Changes in weight that are significant
Insomnia or hypersomnia
Guilt
Agitation
Feelings of worthlessness
Recurrent thoughts of death
An excellent mnemonic to help you remember the signs and symptoms of depression is SIGECAPS:
The first, most commonly used, validated screening tool is the Edinburgh Postnatal Depression Scale (EPDS) (PSI, 2025). This screening tool is free to copy and use without fees or permission, as long as the original copyright is credited by citing the author (Cox et al., 1987). The EPDS has been thoroughly tested and translated into 60 languages for widespread adoption and use (Cox et al., 1987).
The EPDS is composed of 10 questions, rated on a scale of 0 to 3 (Cox et al., 1987). The person is asked to circle one of the four possible answers that best indicate how they have been feeling, just in the last 1 week(Cox et al., 1987). The following statements are included (Cox et al., 1987):
“I have been able to laugh and see the funny side of things.”
“I have looked forward with enjoyment to things.”
“I have blamed myself unnecessarily when things went wrong.”
“I have been anxious or worried for no good reason.”
“I have felt scared or panicky for no good reason.”
“Things have been getting on top of me (too much for me).”
“I have been so unhappy that I have had difficulty sleeping.”
“I have felt sad or miserable.”
“I have been so unhappy that I have been crying.”
“The thought of harming myself has occurred to me.”
When scoring the EPDS (Cox et al., 1987):
0-6 potentially indicates no or minimal depression
One of the most well-known depression screeners in the psychiatry world is the Patient Health Questionnaire or the PHQ-9 (Kroenke et al., 2001; Sidebottom et al., 2012). Modified in a few different ways for different age groups and shortened versions for more speedy screening, the PHQ-9 is a screening tool that is composed of 9 questions that are directly based on the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR) clinical diagnostic criteria for depression (Kroenke et al., 2001; Sidebottom et al., 2012). The PHQ-9 is an easy-to-score tool, available in multiple languages, that has been specifically validated for perinatal use (PSI, 2025). This tool is also free to use without permission.
The PHQ-9 is composed of the following 9 questions, rated on a scale of 0 to 3, with 0 meaning “not at all”, 1 meaning “several days”, 2 meaning “more than half the days”, and 3 meaning “nearly every day” (Kroenke et al., 2001; Sidebottom et al., 2012):
“Little interest or pleasure in doing things”
“Feeling down, depressed, or hopeless”
“Trouble falling asleep or staying asleep, or sleeping too much”
“Feeling tired or having little energy”
“Poor appetite or overeating”
“Feeling bad about yourself—or that you are a failure or have let yourself or your family down”
“Trouble concentrating on things, such as reading the newspaper or watching television”
“Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual”
“Thoughts that you would be better off dead or of hurting yourself in some way”
The person is asked to select which choice indicates how often they have been bothered by any of these problems over the last 2 weeks(Kroenke et al., 2001; Sidebottom et al., 2012).
When scoring the PHQ-9, the score can range from 0 to 27 at a maximum (Kroenke et al., 2001; Sidebottom et al., 2012):
0-4 potentially indicates no depression
5-9 potentially indicates mild depression
10-14 potentially indicates moderate depression
15-19 potentially indicates moderately severe depression
20-27 potentially indicates severe depression
It is important to note here that any positive answer to the final question #9 would necessitate a clinical evaluation as soon as possible, given that it is assessing for suicidal ideation.
The Postpartum Depression Screening Scale (PDSS) is a 35-item screening tool with a 5-point Likert scale where 1 indicates that the person “strongly disagrees” versus a 5, which would indicate that they “strongly agree” (Beck & Gable, 2000). This longer screening tool that covers a more thorough review of the symptoms of postpartum depression, can still be completed in only five to ten minutes, and has a 7-question short form that, if completed with a score of greater than 14, would then require the long form to be completed as well (Beck & Gable, 2000). The PDSS is meant to be used after the first 2 weeks of the postpartum period (Beck & Gable, 2000).
Now also available for open access within the public domain, the PDSS has been translated into multiple languages, is validated for phone screening as well, and is a very common choice of screener for mothers who have infants who are admitted to the NICU (Beck & Gable, 2000; PSI, 2025).
The PDSS asks questions across seven main categories (Beck & Gable, 2000):
Loss of self
Guilt and shame
Sleeping/eating disturbances
Anxiety/insecurity
Cognitive impairment
Emotional lability
Contemplation of self-harm
When scoring the PDSS, the range of scores is from 35 to 175 (Beck & Gable, 2000). The PDSS score can be interpreted as follows (Beck & Gable, 2000):
35-59 potentially suggests normal adjustment to motherhood
60-79 potentially indicates significant symptoms of postpartum depression
≥ 80 is generally used as the cut-off to indicate potential major postpartum depression
The PDSS, like the PHQ-9, asks the person to rate how much they agree or disagree with the statements based on how they have been feeling for the past 2 weeks(Beck & Gable, 2000).
A potential diagnosis of postpartum depression might be indicated by a screening tool that is provided to a postpartum mother. If the screening tool is positive and concerning for postpartum depression, more assessment and questions are necessary to diagnose formally. Often described as the “2 blue weeks”, if 5 or more of the symptoms of depression we have discussed are present for at least 2 weeks, we are considering a diagnosis of major unipolar depression “with peripartum onset” specifier (APA, 2022). Keep in mind that the “with peripartum onset” specifier is only meant to be used within 4 weeks of birth (PSI, 2025).
While the symptoms of postpartum depression are in line with those of major unipolar depression, they might present slightly differently in postpartum mothers. For example, when talking with these mothers, they might seem significantly overwhelmed, not caring for themselves, saying things that make you think they are withdrawing from family members or even their baby, and making comments like “I don’t feel like myself” or “I feel like I cannot cope” (PSI, 2025). In addition, and especially noted within the Black, Indigenous, and People of Color (BIPOC) community, these mothers might complain of more somatic symptoms, including headaches, gastrointestinal issues, and/or back pain (PSI, 2025). It is important to look for these signs when working with postpartum mothers and not brush them off as being expected components of having a new baby and being a postpartum mom.
Postpartum depression is historically underdiagnosed and undertreated (PSI, 2025). Without identification and treatment, postpartum depression symptoms can persist and be experienced for months, even for years (Hantsoo, 2025). In fact, in one study conducted by Putnick et al. (2020), 25% of mothers reported still experiencing postpartum depression three years after their babies were born (Putnick et al., 2020)! Early identification and active treatment are essential for these mothers.
The first-line treatment for depression often involves therapy, such as Cognitive Behavioral Therapy (CBT). CBT is thoroughly evidence-based and is one of the most broadly used forms of therapy (Psychology Today, 2022). It is a form of psychotherapy that works on recognizing negative or maladaptive thoughts, bringing awareness to those thoughts, learning to challenge them, and ultimately working to change thinking patterns to be more realistic, positive, and adaptive to life situations (Psychology Today, 2022). CBT is the evidence-based treatment recommendation for depression (Psychology Today, 2022).
Another form of talk therapy that is often used for depression is interpersonal psychotherapy (IPT). IPT is another form of evidence-based talk therapy that focuses on improving interpersonal relationships in order to improve overall mood and mental health (Cleveland Clinic, 2024).
Other than therapy or even in addition to therapy, psychotropic medications can be extremely helpful for the treatment of postpartum depression (National Institute of Health [NIH], 2023). In fact, according to research on the treatment of depression, it has been found that a combination of both psychotherapy and psychotropic therapy performs significantly better for improving function and quality of life when compared to each treatment used individually (Kamenov et al., 2017).
The first line of psychotropic treatment for depression is Selective Serotonin Reuptake Inhibitors (SSRIs) (Cleveland Clinic, 2022a). SSRIs are antidepressants that block the reuptake and recycling of serotonin, which allows more serotonin to be available in the brain (Cleveland Clinic, 2022a). Depression is one such condition that is associated with lower-than-normal serotonin levels (Cleveland Clinic, 2022a). Serotonin within the brain helps regulate mood (Cleveland Clinic, 2022a). Coined the term “the feel-good” neurotransmitter, at normal levels, it enables better focus, more emotional stability, and an overall happier and calmer demeanor (Cleveland Clinic, 2022a). Serotonin also plays a role in the quality of our sleep, digestion, wound healing, bone health, and sexual health (Cleveland Clinic, 2022a). Because of the roles that serotonin plays, an SSRI potentiating a higher level of serotonin allows for a clear understanding as to why it would be a beneficial treatment for postpartum depressive symptoms.
SSRIs, including sertraline, paroxetine, fluoxetine, and escitalopram, are relatively well-tolerated and, after a period of generally 4-6 weeks, have been shown to increase the serotonin levels enough for people to notice a difference in their overall mood and a decrease in their symptoms (Cleveland Clinic, 2022a). The most common side effects of SSRIs include nausea and diarrhea. These occur because one of the main sites of serotonin receptors is in the stomach. When serotonin levels increase in the brain, they also increase in the stomach. These side effects generally subside within the first few days once the body acclimates to higher levels of serotonin in the gut.
SSRIs are the first-line treatment for depression in all patients. However, because SSRIs are also one of the most well-studied drug classes in breastfeeding, SSRIs are also generally considered the best choice for lactating mothers experiencing postpartum depression (PSI, 2025; Gandhi-Patel, 2023). For mothers who have not been on an SSRI before, sertraline is generally where we start, as it is one of the best-tolerated SSRIs. Please see the following table for medication dosage guidance as well as information about what is known from the research regarding the percentages of SSRI medications that have been found in breast milk.
Table 1: SSRIs for Lactating Mothers
SSRI
Dosages
% of Maternal Dose Found in Breastmilk
Prescribing Tips
Sertraline (Zoloft®)
Starting: 25 mg Range: 50-200 mg
0.4-2.3%
*Most commonly prescribed in pregnancy and postpartum
Paroxetine (Paxil®)
Starting: 10 mg Range: 20-40 mg
0.1-4.3%
*Reports are consistent with low levels of exposure in a large number of studies *Marked withdrawal effects if the dose is missed
Citalopram (Celexa®)
Starting: 10 mg Range: 20-40 mg
2.5-9.4%
*In fewer studies than sertraline, but showing low levels of exposure to breastfeeding infants *Concern of QTc prolongation with doses over 40 mg (need EKG)
Escitalopram (Lexapro®)
Starting: 5 mg Range: 10-20 mg
3.9-7.9%
*In fewer studies than sertraline, but showing low levels of exposure to breastfeeding infants *It is said to work faster than other SSRIs
Fluoxetine (Prozac®)
Starting: 10 mg Range: 20-80 mg
1.1-12.0%
*If taken during pregnancy and working for the patient, do not switch during postpartum (compatible with breastfeeding) *Especially at higher doses, because of long half-life, might be more likely to be detectable in infant serum
(PSI, 2025)
While SSRIs can be found in breast milk, studies have indicated that these amounts are negligible (Gandhi-Patel, 2023). Namely, with sertraline, there have not been any clear reports of the small amount found in breast milk causing any side effects or causing any developmental abnormalities in breastfed infants (Gandhi-Patel, 2023). Fluoxetine and citalopram, as included in the chart above, are great SSRI options too, but they carry more caution than the others due to the finding that more of these drugs pass into breast milk and less research has been done on their use (Gandhi-Patel, 2023).
Other serotonin-potentiating treatment options can also include serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine, which also works to increase levels of norepinephrine, the neurotransmitter that plays a role in attention, motivation, emotions, and memory storage (Endocrine Society, 2022). Low levels of norepinephrine are also implicated in several mental health conditions, including depression (Endocrine Society, 2022). Tricyclic antidepressants (TCAs) like nortriptyline have also been considered to be safer medications to take while breastfeeding, as minimal amounts are found to be in breast milk and there are no current reports of side effects (Gandhi-Patel, 2023).
While most things we consume, including antidepressants, are passed into breast milk, the potential benefits of breastfeeding and the treatment of postpartum depression for both the mother and the child are considered to significantly outweigh the less likely risks (UCSF Department of Pediatrics, 2024; PSI, 2025). Also, as mentioned briefly in Table 1, if a patient has been taking a specific antidepressant during or before their pregnancy, it is generally recommended that they continue taking what is working for them, even if it is not necessarily the first choice for breastfeeding. While the risks versus benefits must be weighed, it is often preferred to continue a psychotropic medication that is working for a patient rather than risking the relapse of a mental health condition such as depression (PSI, 2025). While lowering a dosage might seem like a quick, viable option, it is important that the dosage is not lowered to a point where symptoms re-emerge. As we have learned, an untreated, or in this case, an undertreated mental illness, can be far more dangerous and impactful on an infant than the low risk of exposure of the infant to mom’s milk containing trace amounts of her medication (PSI, 2025).
In 2019, brexanolone (Zulresso ®) received its first Food and Drug Administration (FDA) approval specifically for the treatment of postpartum depression (Mayo Clinic, 2025). Brexanolone is an intravenous neurosteroid (Mayo Clinic, 2025; Reddy et al., 2023). It is a progesterone-derived allopregnanolone (naturally occurring neurosteroid that is made from the hormone progesterone) that activates GABA-A (GABA, or Gamma-Aminobutyric acid, is our neurotransmitter that is known for producing a calming effect) receptors, and in turn rapidly relieves postpartum depressive symptoms (Reddy et al., 2023; Cleveland Clinic, 2022b). In fact, the clinical studies have shown that some people experience improvement of their postpartum depression symptoms within just a few hours of administration initiation (Reddy et al., 2023). This is huge given that conventional SSRI treatment generally takes 4-6 weeks to work!
Brexanolone, available only through a restricted program called Zulresso ® REMS (Risk Evaluation and Mitigation Strategy) Program, has to be used inpatient and administered via the intravenous route over a period of 60 hours (Mayo Clinic, 2025). It can be utilized for adults as well as adolescent mothers who are at least 15 years old (Medscape, 2024a). Dosing is specifically rate-controlled. It is initiated at 30 mcg/kg/hour for the first four hours (Medscape, 2024a). It goes through steady increases in dose to a maximum of 90 mcg/kg/hour at the 24-hour point, if it is tolerated (Medscape, 2024a). Then, it is titrated down again slowly for the remaining infusion time (Medscape, 2024a).
While brexanolone is being administered, it is important to check the patient for symptoms of sleepiness or even excessive drowsiness every 2 hours (Mayo Clinic, 2025). It has been seen that this medication can cause sudden loss of consciousness/syncopal episodes (Mayo Clinic, 2025; PSI, 2025). Because of this, it is necessary to have the patient who is receiving a brexanolone infusion on continuous pulse oximetry for the duration of treatment (Medscape, 2024a). Brexanolone can also cause headache, irritability, and agitation, and in some cases, can lead to individuals experiencing worsening depression or suicidal ideation (Mayo Clinic, 2025; Reddy et al., 2023).
In the lactation study that was conducted on brexanolone, composed of 12 women, it was found that this medication does transfer into breast milk (Medscape, 2024a). However, the percentage that is said to reach the breastfeeding infant is about 1-2% of the maternal dose (Medscape, 2024a). Therefore, it is considered a low risk (Medscape, 2024a). As in all cases like this, the potential benefits of treatment for mom and breastfeeding for the infant must be weighed against the potential risks. Some mothers choose to defer breastfeeding for the 60 hours while they receive treatment. To maintain supply, these mothers can pump and discard their breast milk for the treatment period as well as for 4 days after (Larson, 2024).
An oral medication, zuranolone (Zurzuvae ®), was approved by the FDA in 2023 as the first oral medication to treat postpartum depression (U.S. Food & Drug Administration [FDA], 2023; NIH, 2023; PSI, 2025). Zuranolone, an oral neurosteroid, is an oral capsule, which is said to work in the body in a very similar way to brexanolone (FDA, 2023; PSI, 2025). In zuranolone’s clinical trials, symptom improvement was seen in as little as 3 days (Woodcock, 2024)! Again, this is way faster than traditional antidepressants.
The daily recommended dosage of zuranolone is 50 mg, taken once every day for 2 weeks, in the evening, along with a fatty meal (FDA, 2023; PSI, 2025). If 50 mg is not tolerated, a lower dose of 40 mg is recommended (Woodcock, 2024). Zuranolone most commonly can cause somnolence and dizziness (Medscape, 2024b). The one clinical lactation study that was done with 14 women demonstrated that zuranolone can be present in breast milk in low levels (Medscape, 2024b). Because of the potential exposure, some mothers can choose to defer breastfeeding for the 14 days while they receive treatment. To maintain supply, these mothers can pump and discard their breast milk for the treatment period as well as for one week after (Larson, 2024).
Zuranolone can also be taken in addition to an antidepressant such as sertraline (Woodcock, 2024). This is beneficial because zuranolone can help to mitigate postpartum depression symptoms quickly while the SSRI is taking the time it needs to kick in. Because zuranolone treatment is stopped after 2 weeks, continuing therapy with an SSRI onboard might be a good option for some women.
The ACOG recommends that brexanolone and zuranolone be considered for the treatment of moderate to severe postpartum depression in patients with symptom onset in the third trimester or within 4 weeks postpartum (Larson, 2024).
Postpartum depression, while still way underdiagnosed and undertreated, is a well-known problem. Postpartum anxiety, on the other hand, is not talked about nearly as much. Postpartum anxiety can be just as debilitating (Felton, 2024). Postpartum anxiety may be observed by itself or can actually present in addition to postpartum depression. Let’s take a look at what is most important to know about postpartum anxiety.
Postpartum anxiety is said to affect about 15-20% of mothers (PSI, 2025). This mental health concern, much like postpartum depression, is unfortunately relatively common, and just about as common as postpartum depression!
People with anxiety disorders frequently have intense, excessive, and persistent worry and fear (APA, 2022). Postpartum anxiety is marked by a heightened generalized nervousness as well as a constant feeling of uneasiness (Texas Children’s, 2025a). Many new mothers are told that sadness is a common experience after having a baby, but not every mother is aware that feeling extremely anxious, or even having panic attacks, can be just as common (Felton, 2024). Panic attacks, which can indicate panic disorder, are repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (APA, 2022). These feelings of anxiety and panic can interfere with daily activities and are difficult, if not impossible, to control (Mayo Clinic Staff, 2018).
Postpartum anxiety generally manifests as intrusive thoughts, difficulty relaxing or sleeping even when the baby is resting, and an overwhelming feeling of concern about keeping their baby protected and safe (Texas Children’s, 2025a).
For postpartum mothers suffering from anxiety, the signs and symptoms can include (APA, 2022; PSI, 2025):
Excessive worry
Inability to control worry
Restlessness or feeling on edge
Agitation that can escalate to anger
Difficulty concentrating
Issues sleeping
Somatic complaints such as palpitations, gastrointestinal distress, muscle tension
Panic attacks can occur as a result of a trigger or can be completely random (APA, 2022). Signs and symptoms of panic attacks, more commonly known as panic disorder, can include (APA, 2022):
Chest pain
Trembling
Shaking
Nausea
Chills or hot flashes
Numbness or tingling
Sweating
Palpitations
Feeling dizzy or light-headed
Sensation of being choked
Stomach pains
Rapid heart rate
Feeling of detachment from reality
Feeling of impending doom
Because the signs and symptoms of panic-level of anxiety can be so severe, many individuals feel as if they are having a heart attack or that they might die (APA, 2022). Therefore, it is common for these patients to come to the emergency department to be assessed.
While there are way more options for the screening of postpartum depression, some of the same screening tools can be utilized to help identify postpartum anxiety, too. We will talk about 3 excellent screening tool options: the GAD-7, PHQ-4, and the PSAS.
The Generalized Anxiety Disorder-7 (GAD-7) is one of the most well-known screening tools for anxiety (Spitzer et al., 2006). While it primarily is used in the adult and pediatric population to identify GAD, studies have shown that it provides great usefulness in the screening for anxiety during pregnancy as well as in the postpartum period (Vogazianos et al., 2022; Lutkiewicz et al., 2024).
This tool is a self-assessment questionnaire that has 7 items, measuring the severity of those 7 items depending on how often they occur. This tool is available in the public domain, so no permission is required to reproduce or distribute it (Spitzer et al., 2006).
The person is asked to pick a response that quantifies how much of a bother these 7 items have been over the last 2 weeks, on a scale from 0 to 3, where 0 is “not at all”, and 3 is “nearly every day”. These items include (Spitzer et al., 2006):
The PHQ-4 is actually just a shortened version of the PHQ-9 that we discussed earlier in this course. Studies have demonstrated that the PHQ-4 is a valid and reliable screening tool for assessing both anxiety and depression (Adzrago et al., 2024).
This shortened version asks 4 questions and again asks the individual to pick a response that quantifies how much of a bother these 4 problems have been over the last 2 weeks, on a scale from 0 to 3, where 0 is “not at all”, and 3 is “nearly every day” (PSI, 2025). The questions it asks about include (PSI, 2025):
Feelings of anxiousness, or being on edge
Not feeling able to control worrying
Feeling down or hopeless
Getting little pleasure in doing things once enjoyed
As you might notice, the PHQ-4 includes 2 questions from the PHQ-9 and 2 questions from the GAD-7 (Kroenke et al., 2009). Because of this, this tool is used as a quick screener for both anxiety and depression (Kroenke et al., 2009).
When scoring the PHQ-4, it ranges from a total of 0 to 12 points maximum (Kroenke et al., 2009; PSI, 2025):
0-2 potentially indicates no anxiety and/or depression
For quite some time, there was no postpartum-specific anxiety screening tool like the tools we had for detecting signs and symptoms of postpartum depression. The Postpartum Specific Anxiety Scale (PSAS) is a 51-item questionnaire that was specifically designed to assess the frequency of how often specific anxieties are experienced during the postpartum period (Fallon et al., 2016; Massachusetts General Hospital (MGH) Center for Women’s Mental Health, 2017).
The PSAS asks questions across 4 major themes, including (Fallon et al., 2016):
Infant safety and well-being anxieties
Maternal competence and attachment anxieties
Psychosocial adjustment to motherhood anxieties
Baby care-specific anxieties
Each item is rated on a 4-point Likert scale where 1 indicates “never” and 4 indicates “almost always” (Fallon et al., 2016).
When scoring the PSAS, the total score can range from 51 to 204 (Fallon et al., 2016). Very similar to the other screening tools we have discussed, the higher the score, the higher the reported frequency of the specific postpartum anxieties, the higher the severity level of anxiety that is potentially indicated (Fallon et al., 2016). The PSAS is said to be a valid and reliable screening tool to assess for postpartum anxiety (Costas-Ramón et al., 2023).
While there is no formal diagnosis of “postpartum anxiety” or the “with perinatal onset” specifiers to best define it in the DSM-5-TR (at least not yet!), the symptoms are those of generalized anxiety disorder (GAD) (APA, 2022; PSI, 2025). With 3 or more symptoms, as we have discussed above, we are considering a diagnosis of GAD (APA, 2022; PSI, 2025).
The hallmark here? When we talk to a mother during our assessment and ask her to determine the cause or the source of her anxiety, if her response is something in relation to the infant, such as the infant’s health, her ability to succeed in motherhood, her concern over her child’s safety, the source of her anxiety is perinatal in nature, specifically in relation to the postpartum period. Therefore, we treat it as postpartum generalized anxiety disorder.
The one major hold-up is the fact that in order to be diagnosed with GAD, the time frame for the symptoms to be experienced must be at least 6 months (APA, 2022). For mothers who are experiencing these symptoms of anxiety during the postpartum period, especially if they are severe and causing issues with basic functioning, even if it is not quite 6 months yet, a diagnosis of anxiety might be entirely valid.
Just like postpartum depression is very treatable, so is postpartum anxiety. Postpartum anxiety can be treated with psychotherapy, diaphragmatic breathing, psychotropics, or support groups, or, better yet, even a combination of these options.
CBT is the gold standard for psychotherapy treatment for anxiety disorders, just as it is for depression (APA, 2022). Yet again, the goal is to question those maladaptive thoughts and emotions and reframe thinking to help turn off the spiraling thoughts and harness more control over the physical symptoms of anxiety, starting with the thoughts that elicit these symptoms (APA, 2022; Collier, 2021).
Another one of the modalities for anxiety treatment is the teaching of and use of breath work (Expecting and Empowered, 2019; Children’s Hospital Colorado, 2020). Breathing dysfunction is something that can occur due to stress and anxiety (Expecting and Empowered, 2019). With stress comes the inability to be fully aware of one’s breath work, potentially breath holding or short, shallow breathing, leading people to default to “chest breathing”, utilizing smaller muscles in the neck and shoulders, which often does not optimally oxygenate the blood, causing potential build-up of tension and pain in the upper part of the body (Expecting and Empowered, 2019). What is preferred is what is known as “diaphragmatic breathing”, where the deeper, more thorough work of the diaphragm in conjunction with the pelvic floor, allows for deeper breaths that allow for better oxygenation of the blood and more optimized lymphatic drainage to remove toxins from the body (Expecting and Empowered, 2019).
There is a reason why breathing techniques and pregnancy have long been associated. Breath work is well known to help with stress and anxiety. It has been studied in research and shown to activate mental processes in the brain, stimulating the release of endorphins, which we know are hormones providing natural pain relief (Expecting and Empowered, 2019). Breath work also helps the blood vessels dilate, which causes a decrease in blood pressure and an increase in blood oxygen levels (Expecting and Empowered, 2019). With slower, deeper, more controlled breaths, and bringing attention to intentionally doing this, the autonomic nervous system is calmed, sending the message to the brain that it can relax (Expecting and Empowered, 2019; Children’s Hospital Colorado, 2020).
Additional nonpharmacological methods of mitigating anxiety include engaging in regular physical activity (as tolerated and recommended by mom’s OBGYN), getting outside for some fresh air and even a walk, getting enough sleep, journaling worries and concerns to give them a safe home for thought and consideration without them overwhelming the mind, meditation, and practicing mindfulness to focus on the here and now (Collier, 2021).
It would also be extremely helpful if the mom could be offered additional support during this time. With someone offering to help with the baby, mothers are better able to care for themselves. Even just getting to hand off the baby for 30 minutes or an hour can give the mother the opportunity to take a break, get some sleep, or take a relaxed shower or bath to help bring them back to feeling a bit more like themselves. It is important to remember that moms are still physically recovering from having their baby and need this time to take care of themselves, too.
In terms of pharmacological treatment for anxiety, as mentioned above when discussing the treatment of depression, SSRIs are also indicated for the treatment of anxiety disorders.
In addition, while brexanolone (Zulresso ®) and zuranolone (Zurzuvae ®) only have FDA approval specifically for the indication of postpartum depression, because the neurotransmitters associated with depression are the same that are associated with anxiety, brexanolone and zuranolone have both been shown to improve both depressive and anxiety symptoms (Mayo Clinic, 2025; Reddy et al., 2023; Medscape, 2024a; Woodcock, 2024; FDA, 2023; Medscape, 2024b).
For women with more severe symptoms of anxiety or insomnia, in relation to anxiety, or if she is experiencing panic attacks, a benzodiazepine such as lorazepam or clonazepam can be used for a short period of time (Nonacs, 2024). Because benzodiazepines are fast-acting, generally bringing relief within an hour of taking them, they can be very helpful for acute situations of high anxiety. While there are not many studies looking at the safety of taking a benzodiazepine while breastfeeding, the existing studies have quantified low or undetectable levels of benzodiazepine in breastfed infants’ serum (Nonacs, 2024). Although some adverse effects on the infant have been reported, they are thought not to be serious, with sedation being the most reported adverse effect (Nonacs, 2024). Infants who are exposed to benzodiazepines in breast milk should be monitored for sedation, especially in those with the mother taking higher doses or on any additional potentially sedating psychotropic medications (Nonacs, 2024). Benzodiazepines should be utilized as a short-term solution while waiting for SSRIs to take effect, or specifically for panic attacks, due to the addictive nature of this drug class.
While this course is primarily meant to focus on postpartum depression and anxiety, it would be a disservice to postpartum mothers everywhere if the opportunity were not taken to at least briefly discuss postpartum obsessive-compulsive disorder (OCD) and postpartum psychosis. The reason we will discuss them concurrently will become clear shortly!
Obsessive-compulsive disorder (OCD) is one type of anxiety disorder. Earlier in this course, we talked about how anxiety can be characterized by intrusive thoughts. Remember, intrusive thoughts are these recurrent, unwanted thoughts that pop up into our heads that can cause stress and worry. The difference between intrusive thoughts in generalized anxiety and those experienced in OCD is all in how they are handled (Lamberti, 2024). In generalized anxiety, these intrusive thoughts occur, resulting in heightened anxiety and fear, which generally leads to the individual avoiding the situations that might be triggering these thoughts (Lamberti, 2024). In OCD, these intrusive thoughts lead the individual to engage in repetitive behaviors in an attempt to counteract or neutralize the thought (Lamberti, 2024). Engaging in these repetitive behaviors helps to lower their anxiety level (Lamberti, 2024).
OCD is not high on the list of differentials for anyone working with a postpartum mother, but it should be. Frankly, it is just less widely understood. Let’s work on changing that! The prevalence of postpartum OCD is about 17% (MGH Center for Women’s Mental Health, 2021a). Pregnancy and the postpartum period are said to be a time of increased vulnerability to OCD (MGH Center for Women’s Mental Health, 2021a). In fact, approximately 1 in every 210 women may develop new postpartum-onset OCD every week (MGH Center for Women’s Mental Health, 2021a). That means that the experienced OCD is brand new during their postpartum period, indicating they did not previously have symptoms, or they were not diagnosed prior to this period (MGH Center for Women’s Mental Health, 2021a). Women with existing OCD prior to giving birth are at an increased risk for postpartum OCD (Texas Children’s, 2025b). Because of this, although current guidelines do not specifically recommend screening for OCD in the postpartum period like they do for depression, it would be a great idea to incorporate postpartum OCD as well.
OCD is characterized by the existence of obsessions and compulsions. Most commonly, the obsessions, or intrusive thoughts, are about germs or being contaminated or even about the need to arrange and order things in a specific way for symmetry or general order (International OCD Foundation, 2025a; APA, 2023). These types of obsessions are “undone” by excessive showering, washing, or cleaning, or even repetitive checking or putting things in a place that “feels right” (International OCD Foundation, 2025a). These “undoing” activities are the compulsions. Compulsions are named for the fact that the individual feels that they MUST be done. Postpartum OCD obsessions and compulsions can often include these same components, but they can also present in a unique way. In postpartum OCD, the obsessions, or intrusive thoughts, are generally specifically related to harming the infant (MGH Center for Women’s Mental Health, 2021a). The types of intrusive thoughts that a postpartum mother might experience can include (MGH Center for Women’s Mental Health, 2021a):
Unwanted images or thoughts of harming the infant on purpose
Thoughts of harming an infant by accident because of being distracted
Sexually harming the infant
While general thoughts of wanting to protect your baby are normal, it is not normal to be thinking things like “what if I drop my baby from the top of the stairs?” or “I keep seeing this image of me pouring hot water on my baby, what if I actually just do it one day?” or “what if I accidently touch them inappropriately during a diaper change?”. As you might surmise, these thoughts can be incredibly horrifying to a mother. These unsolicited thoughts and images create a lot of anxiety, but she is very aware that these are not normal thoughts, and she has no actual interest in harming her child(PSI, 2025). Of course, she does not want to harm her child! Why are these thoughts popping up in my head? Why are they consuming me? Why will they not stop?
Many women feel as if they are going crazy or that something more might be wrong with them. These thoughts keep happening; they continue to dwell on them for fear they might come true somehow. This creates more distress, and so again begins the cycle of more upsetting thoughts (Texas Children’s, 2025b). Some mothers become overly attached to their child, not allowing anyone else to help or hold them, or even completely detached, out of fear that they might harm them somehow (Pelham, 2023). The compulsive rituals they might engage in might include checking on the baby multiple times a night, driving around the block in a certain, routine way, and even complete avoidance of places and things that have appeared in their thoughts and images. These are specific actions, guided by their obsessions, that are actual steps to protecting their baby. Naturally, for fear of losing their child or being wrongly judged by others when they know these things are not right, many mothers are hesitant to share these thoughts and concerns with other people, even their significant other, and might choose to keep them to themselves (MGH Center for Women’s Mental Health, 2021a). Sometimes, if mom does finally speak up to a friend or even a healthcare provider who is not well-versed in postpartum OCD, they might just be told that their thoughts are just normal for an extra-vigilant mother. This is not true. They do not have to suffer in silence.
We need to assess for and ask about these thoughts and/or images, specifically. We need to ask if they are having scary or unusual thoughts that are causing them fear or anxiety (PSI, 2025). We need to share with them that we are safe people to share this with. We need to let these moms know that these thoughts are, unfortunately, quite common, that many moms experience them, and that it is just postpartum OCD! These thoughts are NOT delusions or hallucinations. Also, it helps to remind them that thoughts are NOT actions, they are just thoughts. They are not crazy. Postpartum OCD is very treatable. These thoughts do not just go away with time or more sleep. Once they start, they begin a cycle that takes mothers around and around again, on a loop that they are stuck in (Pelham, 2023). Instead, SSRIs, as we discussed above for the treatment of postpartum depression and anxiety, are very effective at addressing postpartum OCD symptoms (Felton, 2024). An excellent psychotherapy treatment option for postpartum OCD is a type of CBT and the gold standard that is utilized for OCD, called Exposure and Response Prevention (ERP) (PSI, 2025). It involves exposing the individual to situations that trigger their obsessive thoughts and helping them work through the anxiety that is provoked without having to resort to engaging in their compulsions (International OCD Foundation, 2025b).
Postpartum psychosis, sometimes called puerperal psychosis, while rare, is the most serious postpartum psychiatric illness (APA, 2023; Payne, 2024; MGH Center for Women’s Mental Health, 2022). Postpartum psychosis is a medical emergency that requires immediate attention. It is an emergency because it is associated with a high rate of suicide among mothers and harm to the baby (Hantsoo, 2025). It is known to affect 1 to 2 out of every 1,000 postpartum women (PSI, 2025; MGH Center for Women’s Mental Health, 2022). It can present as early as 48 to 72 hours after she has her baby, but, in most women, symptoms develop within the first two postpartum weeks (MGH Center for Women’s Mental Health, 2022). Approximately 40% of women who experience postpartum psychosis do not have any personal history of psychiatric illness at all (MGH Center for Women’s Mental Health, 2021b). We do know that mothers with existing bipolar disorders or schizoaffective disorder are at an increased risk (Payne, 2024; MGH Center for Women’s Mental Health, 2021b). While we know that childbirth is the main trigger in postpartum psychosis, the actual pathophysiology and etiology of how and why this occurs are not well understood (MGH Center for Women’s Mental Health, 2021b).
Postpartum psychosis might begin as simply irritability, insomnia, and restlessness (MGH Center for Women’s Mental Health, 2022). As it continues to develop, it is characterized by (APA, 2023; MGH Center for Women’s Mental Health, 2023; MGH Center for Women’s Mental Health, 2022; Payne, 2024; Hantsoo, 2025):
Rapidly shifting elated or depressed mood
Disorientation/confusion
Coming in and out of consciousness/awareness
Agitation
Disorganized behavior
Erratic, unorganized, illogical speech
Extreme paranoia or suspiciousness
Ideas of reference
Delusions (false beliefs) centered on the infant (e.g., the baby is evil)
Hallucinations (often auditory) that encourage harm to the infant or herself
Because of the nature of the symptoms of postpartum psychosis, it is clear that infanticide and suicide are significant risks for an individual suffering from postpartum psychosis (PSI, 2025; MGH Center for Women’s Mental Health, 2022).
Postpartum psychosis also features a form of intrusive thoughts, just like postpartum OCD. However, these thoughts might accompany delusions, hallucinations, or even ideas of reference (MGH Center for Women’s Mental Health, 2023). These delusions are generally quite bizarre like, their baby is the devil or that they have special powers, their baby is not really theirs, someone is out to steal the baby from their mother, there is some sort of conspiracy involving mom and baby, or even that someone or something else is controlling and manipulating mom’s actions or thoughts (MGH Center for Women’s Mental Health, 2023). The hallucinations might include hearing or seeing things that really are not there. Some women even explain that they experienced command auditory hallucinations that told them to harm their baby (MGH Center for Women’s Mental Health, 2023). Ideas of reference are when a woman with postpartum psychosis thinks that certain events or experiences hold a special, personal significance to them alone, of some sort. An example might be if they are listening to the news and believe that the reporter is speaking directly and only to them. While a father or significant other might not know specifics, they might be able to provide some information on mom acting strangely, behaving differently than normal, or reporting that they have seen or heard things that were not really there. These reports must be taken seriously and investigated.
The sooner postpartum psychosis is identified, the better. Delusions and hallucinations of postpartum psychosis can persist if it is not treated. While many cases, like the ones you hear about on the news, end in tragedy and loss, resulting in legal repercussions and prison for the mother, that does not always have to happen. If a mother is suspected of having postpartum psychosis, she must be evaluated as soon as possible. Because of the risk of suicide and infanticide, close observation and psychiatric hospitalization for the mother is recommended (MGH Center for Women’s Mental Health, 2023).
The gold standard in the treatment of postpartum psychosis includes a mood stabilizer, often lithium, as well as an antipsychotic medication (Hantsoo, 2025). Even in severe cases of postpartum psychosis, we have seen that an appropriate treatment regimen can result in complete remission of symptoms (Bergink et al., 2015).
Earlier, when we were talking about postpartum OCD, did you notice anything that the quoted postpartum OCD thoughts had in common with each other? Take a quick second to scroll back up and take another look if you did not.
See the underlined phrase? It’s the “what if”. The “what if” thoughts are the hallmark of postpartum OCD (PSI, 2025; Texas Children’s, 2025b). Postpartum psychosis thoughts are not “what if”; they are “this will actually happen”. This is the key difference between postpartum OCD and postpartum psychosis! While mom might still feel distressed and disturbed by the thoughts she is having, in postpartum psychosis, she feels compelled to actually act on them (PSI, 2025). In some cases, these thoughts are not as distressing at all, per se. Instead, they are simply a warning, roped into a paranoid thought process or delusion that the mother is experiencing.
Why is it so important to understand the difference between postpartum OCD and postpartum psychosis?
It is extremely important to understand the difference between the two because of how often postpartum OCD is misdiagnosed as postpartum psychosis. When this happens, child protective service reports are often filed inappropriately, generally leading to surprise in-home welfare checks, which elicit additional undue stress and fear on the mother and the family unit. As many as 70% of healthcare providers have missed accurately identifying postpartum OCD obsessions of harming their infant, and 31% of these providers have labeled these thoughts as postpartum psychosis instead (PSI, 2025). It is important to strongly consider if the reported symptoms from either mom or a family member are more in line with postpartum OCD or if they really are psychotic in nature. Just like in all other cases we come across as healthcare professionals, if you truly have a gut feeling that the child is in danger or the mother is in danger to herself, go with the gut feeling and file a report.
It is not often widely discussed how fathers (or significant others) are impacted on a psychological and emotional level by becoming a parent. The truth is that these individuals can also experience symptoms of postpartum depression (PSI, 2025; APA, 2023)!
It is estimated that 10% of new fathers experience paternal postpartum depression (PSI, 2025). It is also known that the prevalence of paternal postpartum depression can increase to over 50% of fathers when the mother has postpartum depression herself (Wainwright et al., 2023)! In fact, maternal postpartum depression is the single strongest predictor of paternal postpartum depression (PSI, 2025). Now, mom does not need another guilt trip or another reason not to share her true feelings. This information is just being shared to bring awareness to the fact that dads can be affected in the postpartum period as well, and if mom is struggling, dad might be too.
Depressive symptoms in fathers look a bit different than those in mothers. First, father’s postpartum depressive symptoms typically spike between 3 to 6 months postpartum, as they are coming down from the exciting, “new dad high” (PSI, 2025). Instead of more sadness we see in moms, the symptoms that often present in new dads include (PSI, 2025; Wainwright et al., 2023; Scarff, 2019; UnityPoint Health, n.d.):
Irritability, frustration, aggressiveness, and even hostility
Distancing himself from mom and baby
Mentally “checking out”
Increased self-isolation
Indecisiveness
Restricted range of emotions
Finding distractions to take up their time instead
Risk-taking behaviors, including substance use
Easily frazzled or stressed
Physical complaints like stomachaches/headaches
It is thought that the number of cases of paternal postpartum depression is underestimated due to the fact that it is so underreported. In many cases, it is someone else who identifies depressive symptoms in a father before he, himself, does (UnityPoint Health, n.d.). For those who do report symptoms to their providers, a very small percentage (one study determined it to be 3%) actually seek out mental health services (PSI, 2025). We know that if dad goes untreated, very similar negative short and long-term effects on both mom and baby, just as we see when mothers have postpartum depression, are possible.
Fathers are also at risk for postpartum anxiety. One meta-analysis conducted on a total of 23 studies, including more than 40,000 people, found that 10% of men experience prenatal and postpartum anxiety (Leiferman et al., 2021). Unlike with paternal postpartum depression, the symptoms of postpartum anxiety in fathers are generally the same as those seen in mothers.
While on the subject of fathers’ experience with PMADs, it is important to bring awareness to and appreciate the experience of significant others of the same gender. The LGBT+ parents’ experiences of conception, birth, and the postpartum time period are under-researched, as research on issues regarding pregnancy has historically been centered within heterosexual relationships (PSI, 2025). More work will still need to be done to study the impact of the perinatal experience on lesbian, gay, bisexual, and transgender couples, as their struggles are similar but different in many ways.
Just remember, it is important to ask about dad and significant others, too!
Women with PMADs, first and foremost, need to be treated without bias. These women require patience, reassurance, active listening, and especially education, even before becoming pregnant.
Nurses can counsel women with PMADs to cut down on other commitments (if possible at all) when pregnant or caring for a new baby, avoid getting involved in stressful situations (again, if possible), and avoid drinking alcohol and excessive amounts of caffeine because these can all interfere with sleep (National Health Service [NHS], 2024). It is also essential to teach these patients to look for the positive things in life, make time to rest and relax, be open about feelings, ask for help, look for local support groups, and eat well (NHS, 2024).
During labor, delivery, and the postpartum period, the nurse must ensure that these patients have everything explained to them to minimize potential anxiety. Pregnant women with known mental health struggles must know what resources are available to them, should they require them. They may need home health care, support groups, and follow-up psychiatric care.
Nurses need to teach their patients (and every pregnant mother, you know, really) what to expect in terms of the emotional roller coaster of the postpartum period. While it is generally a very happy time, it can also be filled with an increased risk for serious and life-altering anxiety and mood disorders.
Advocacy for PMADs is also essential. Now that you have learned so much about postpartum depression, anxiety, OCD, and psychosis, it is a part of your journey now to share it far and wide! Encourage necessary screening when you feel it is appropriate, consider PMADs in your differentials for any pregnant or postpartum mother who has had a child in the last year or so, advocate for mothers you encounter that you might be concerned about, and share with new mothers you come across in your own private circle the resources that are available from PSI (please see resources listed at the end of the course). Also, now that you also know that PMADs can also occur in fathers or significant others, be on the lookout for these symptoms in the support individuals in a mother’s life. We have a crucial role in education and advocacy efforts to help in the identification, diagnosis, and timely treatment of PMADs.
While not all cases of postpartum depression and anxiety can be prevented, we do have the protective factor of education on our side. The more education and a thorough awareness that is brought to this topic, the more we can do to prevent mothers from going through this alone!
It is so important to provide anticipatory guidance for pregnant women and their families. These women and their families need to be educated about what is to be expected during the later stages of pregnancy, the birth, and the postpartum period. While much focus is put on their child, emphasis must be made on the feelings that the mother might have, the physical changes they will go through, the thoughts they might have, the impulses they might experience, and the signs and symptoms to be more aware of in themselves that might be an indication that they need to ask for professional help. When the family or significant other is brought into this conversation, that is just another person who can be aware of what to look out for and is meant to be there for support in the event that additional help is needed. It is also important to emphasize in this conversation how common and prevalent postpartum depression and anxiety (among other perinatal mental health conditions) really are to normalize them and minimize the fear of seeking help. There is still so much stigma surrounding mental health, especially regarding expectant and postpartum mothers. It is also important to explain how treatable these conditions are and that no one should suffer in silence.
Having the opportunity to plan ahead can also be a protective, preventative factor for mothers. Presenting the pregnant mother with a formal postpartum support plan that she can work on herself or with her significant other/support person can help create a better sense of control for the impending period of time in her life when she will likely feel the most unsure of the next best move. Postpartum support plans can include a “to do” list, indicating who is going to be doing what (mom will pump breastmilk, dad will wash the pump parts), meal planning for those few couple weeks (will family help? Meal prepping frozen meals?), childcare for other children, making a list of what other family/friends can help with so that tasks can be delegated, and even notes for a potential nanny or doula, should these services be desired and available (PSI, 2025).
As discussed earlier, a major factor in prevention is early identification. Although not all mothers are universally screened, it is important that healthcare professionals take the opportunity to screen postpartum mothers whenever possible.
Let's take a quick moment to apply what we have learned here! Today, you are seeing a new patient.
Samantha is a 32-year-old woman who had her first child, Abigail, four weeks ago. Abigail was born at 30 weeks 5 days gestation and was promptly admitted to NICU immediately after birth due to her prematurity. Abigail is now almost 35 weeks gestation and still currently in the NICU, working on feeds and gaining weight before she can be discharged.
At the beginning of your discussion, Samantha seems happy overall, though visibly tired. She explained that her husband, Mike, had urged her to come in today. She says that she is adjusting to life after pregnancy just fine. Because she brought up Mike, you ask about him and the rest of her support system during this postpartum period. She explained that Mike had been a great partner throughout her pregnancy and birth, and he continued to support her through their daughter’s NICU stay, but they had been getting easily frustrated with each other lately. She says that Mike had to go back to work right away and that she has been spending every single day in the NICU with Abigail. She feels frustrated that he cannot spend more than an hour or so most days with them, and is worried that Abigail might not form as deep a bond with him because he has had to miss so much time because of work. Samantha says that her family was supportive and helpful for the first week or so, bringing her meals, checking in on her, and assisting them with their pets at home, but their support has dwindled to only every 3–4-day check-ins from them for the last two weeks.
Then, you ask about her birth experience. Samantha explains that it was traumatizing because she suddenly started having abdominal pain and then contractions when she was only 29 weeks pregnant. She was admitted to the hospital, where they tried to stop the contractions and delay birth. Samantha just made it a few more days before Abigail was born. When you ask her about how Abigail is doing now, she shows you her journal of every single day of Abigail’s stay and the diligent notes she has been taking to document everything that has occurred. She explained that the neonatologists and NICU nurses were all guesstimating about another 2-3 weeks for her to hit the minimum weight to be eligible for discharge. She says that Abigail is still struggling with having bradycardia/desaturation episodes while sleeping, and those are what make her the most nervous about taking her home. Mom is also frustrated with the breast pumping process and just wants to be able to exclusively breastfeed, but Abigail is not doing very well at the breast as she is still learning to eat.
Next, you ask Samantha about how she is caring for herself during this time. You also ask about her sleep, nutrition, exercise, and mental health. Samantha says that because she is staying over every night in the NICU, her sleep is constantly interrupted by beeping, lights, nurses, and respiratory therapists completing their routine care of Abigail, and getting up to help with feeds every 3 hours. She says that she has just been eating whatever is available in the hospital cafeteria, which ends up mostly being chicken tenders and fries, but she is more concerned about the expense it has become. She does not currently exercise because she does not have the time. And, regarding her mental health, Samantha says, “It’s probably not great”.
After collecting the rest of Samantha’s medical and psychiatric history, you take a look at the EPDS that she completed when she arrived. When you score it, you come up with a 21, indicating potentially severe postpartum depression. When you inquire about suicidal ideation, she indicates that she has no desire and no plan at this time. Because you are also concerned about her anxiety, given that her child is in the NICU and mom has not really left her side until today, you give her a GAD-7 to complete as well. Upon scoring her GAD-7, her total is 10, indicating potentially moderate anxiety. Because screening is not diagnostic, you ask Samantha to share more with you about her reported low energy, low mood, lack of ability to concentrate, anhedonia, lack of appetite, agitation, and guilt. You also asked about her reported excessive worrying about her daughter, restlessness, and inability to relax. Samantha endorses all of these symptoms and that she has been experiencing them for the last full month.
What are our “red flags” for Samantha, in terms of things that are increasing her risk for postpartum mental health issues?
It is fair to be concerned about Samantha at this point. The “red flags” that might indicate a problem include:
She defined her labor process and birth as traumatic
Her daughter was born prematurely
Her daughter has been in the NICU for a month, and will be for at least another couple of weeks
Her daughter is having brady/desat episodes, worrying mom about taking her home
Mom is staying around the clock in the NICU, exposed to all the stressors of the ICU environment on top of her concern for her baby; She is keeping very detailed notes, hyper-focusing on her child’s health
Mom wanted to exclusively breastfeed, but due to prematurity and the necessity to pump, she is having to wait and is just hopeful that Abigail will eventually be able to tolerate breastfeeding
Mom is not getting quality sleep
Mom is not exercising or eating well
She’s worried about finances
Mom is upset that Dad is unable to be present much because he has to work
Mom and Dad seem to be getting irritated with each other frequently
It sounds like their support system, outside of each other, might be lacking
Mom’s EPDS and GAD-7 screenings are positive
What can we do for Samantha?
After discussing your concerns with Samantha, you normalize her experience, telling her that she is having a normal reaction to her current situation. You validate her birth trauma, her NICU experience that might be at the level of “NICU-itis”, and her feelings that “this is not how it was supposed to be”. After all, because we know that being a NICU parent is a traumatic, life-changing event itself, due to the high level of toxic stress as they are witnessing multiple traumatizing events, sometimes one after the other, it is understandable why 20-30% of NICU parents experience a diagnosable mental health disorder during the first year postpartum (PSI, 2025). Because you believe she is suffering from both postpartum depression and postpartum anxiety, you recommend a therapist she can start seeing weekly to work on some CBT and process her birth trauma. Although you discussed zuranolone, and she seems very interested at first, Mom is nervous about the impact on her milk supply because she is already not producing enough and does not want to use formula in the NICU. Because of this, you then prescribe sertraline 25 mg per day, to titrate up to 50 mg per day in one week as tolerated.
You also recommend that Samantha look into the ability to select a “primary nurse” on both day shift and night shift in the NICU, who could take care of Abigail each time they work until she is discharged, as long as the nurse agrees with this arrangement, and it is permissible in this NICU. That way, she can get to know the nursing staff more and hopefully feel more comfortable leaving the unit to sleep in her own bed every so often, as this can really impact her mental health in a positive way. You also shared with Samantha that PSI has so many supportive resources, including support groups for postpartum moms, even ones specifically for NICU parents, that she can look into joining. This excites her, and she shares how she would love to volunteer as a support group facilitator someday so she can share her postpartum NICU experience with others. You also mention that if Mike would like to come in and see you, too, you would be more than happy to see if he might benefit from some mental health support as well.
Postpartum depression and anxiety are highly treatable perinatal mental health conditions. While it is normal to be tired, somewhat anxious about protecting your child, and somewhat down as you are mourning the life you left behind, it is not normal when your normal functioning is so disrupted by your new thoughts and feelings.
It is “normal” for moms to worry. It is NOT normal for mothers to worry endlessly the way many do. With a culture that constantly rewards hypervigilance as a component of “being the best mother”, comes a reinforcement that unsettling thoughts and feelings might be what everyone else is experiencing or might only be those of a “bad mom”, so you had better not tell on yourself. Speaking up does not make you weak. Speaking up and getting the help you need is admirable. There is no reason to suffer alone in silence when there are so many things that we can do to help.
When working with postpartum families, utilize a trauma-informed approach, focusing on listening and validating, promoting safety, educating, empowering resiliency, and doing what can be done to avoid re-traumatizing (PSI, 2025). Make sure to check in with yourself on your own biases and be culturally sensitive in your approach to all mothers and families. Because we know that issues like chronic exposure to racism and a lack of health equity can contribute to PMADs, do your part in working to decrease this problem by being more self-aware and leading with compassion when working with postpartum families.
Finally, while intended specifically for the identification, diagnosis, and treatment of the aforementioned PMADs in your patients, please also use what this course discussed as a reminder to check in on the postpartum mothers in your own life!
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Implicit Bias Statement
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.
Postpartum Support International (PSI) is a fantastic resource for all things PMADs. This link brings you to another quick resource for all PMADs and their signs, symptoms, risk factors, and treatment options: Visit Source.
For prescribing medical professionals, if you have a question about mental health care related to pregnant or postpartum patients, you can reach out to the Perinatal Psychiatric Consult Program through PSI. They are specialist in the treatment of PMADs and offer a free service to help you, available by appointment: Visit Source.
PSI also offers many PMAD-related trainings as well as a certification (PMH-C): Visit Source.
Massachusetts General Hospital (MGH) Center for Women’s Mental Health Reproductive Psychiatry Resource and Information Center is a wealth of knowledge and support to equip providers and health care professionals with the knowledge needed to care for mothers at risk for and with PMADs: Visit Source.
Massachusetts General Hospital (MGH) Center for Women’s Mental Health hosts a WEEKLY virtual rounds for all healthcare professionals on Wednesdays from 2-3 pm ET. They answer questions, discuss clinical cases, and share resources to help in guiding decision-making for the medication management of pregnant and postpartum women. Learn more at: Visit Source.
Suicide and Crisis Hotline offers 24/7 free and confidential support for people in distress: Call or text: 988
National Maternal Mental Health Hotline that is available 24/7 as a free and confidential hotline for pregnant and postpartum mothers; Available for those who speak English or Spanish: Call or text: 1-833-852-6262
Postpartum Support International (PSI) is an excellent resource for mothers and families! This line can be called or texted to get basic information, support, and resources. *NOTE: This is not a hotline; it is a helpline. That means that messages are not provided immediately. They are provided within 24 hours, during business hours: 1-800-944-4773
Breastfeeding and medications: Mother to Baby: 866-626-6847
The Blue Dot Project raises awareness of PMADs, shares the blue dot as a symbol of solidarity and support, and works to combat the stigma and shame of PMADs: Visit Source.
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