Postnatal mood disorders - a personal reflection

Pregnancy and Postpartum Mood Disorders – Mothers and Fathers                                  

After the birth of my second child I developed postpartum depression, in my situation it manifested as anxiety and hyper vigilance. I did not immediately seek help and as a result my family and I suffered needlessly for longer. My husband encouraged me to get support when he noticed I was struggling and this began my journey to recovery.

I do not know why I was unable to admit I was struggling, looking back I think I felt I should be able to manage and my perception that I was failing filled me with dread that I would be discovered and deemed a bad mother.

Studies have revealed that as many as 1 in 5 women experience mental health problems in pregnancy or after giving birth.

·      70-100% of women experience unwanted, intrusive thoughts about their baby

·      10-15% of women can experience mild to moderate postnatal depression

·      postnatal depression may also affect approximately 10% of fathers and a lack of research means this is likely underestimated

What does postpartum depression look like?

Well for me I was constantly worrying about my children, which meant I did not feel comfortable being away from them, but at the same time I was worried I was incompetent and sought to delegate tasks such as putting coat on baby or giving baby a bath. I worried my baby would wriggle out of my hands during bath and would drown in the 1 second their face might touch the water, so when my husband got home from work I lied and said there had been no time during the day for the baby bath so asked him to do bath while I prepared dinner. I was uncomfortable carrying baby while walking up or down the stairs, so there were many days where baby and I stayed either upstairs or downstairs depending on whether my husband had placed baby in moses basket in sitting room before he left for work. I was terrified I would dislocate baby’s shoulder or elbow or pinch baby’s fingers or thumb when putting on their coat, so for the first 3 months of baby’s life I always asked someone else to do this and made an excuse of needing to get the car started, or to carry bag out to car, or pop to the toilet before heading out so I would not be discovered.

If anyone else was pushing baby in the buggy it filled me with dread, I was convinced a car would mount the footpath and crash into the buggy and only I could keep baby safe. On one occasion my family and inlaws took train together into town, upon exiting the train my inlaws took buggy and toddler down lift while my husband and I walked down the stairs. We walked out different exits and I was having an internal panic attack convinced my toddler would wander off and be snatched by predator or inlaws would let go of buggy and it would tip onto road in front of a truck. I rushed to catch up to them and sobbed with relief when reunited.

I also found leaving the house and having responsibility for any kind of decision-making filled me with anxiety. Baby brain had me feeling incompetent and anxious.

My husband and I were out one day and we were about to order rolls to take away for lunch. While in the queue my toddler needed the toilet so my husband left to take her and said he would meet me at entrance to playground. He was leaving me in charge of ordering the food. I panicked. I asked him how many rolls to order for us. He said “one each plus one for the kids to share”, and then left. I stood there mentally repeating his instructions, one each, so that’s 4, plus one for the kids to share, ok that makes 5 rolls to order. I stood in the queue reading the menu trying to decide which roll my husband would like, which roll for the 3 year old, which roll for 8 months old, plus which roll for the kids to share. I placed the order. I waited for the order to be prepared. I collected the order and started walking to playground. I placed rolls in buggy basket and only then, several minutes after my brain first computed “one each plus one to share” as 5, did my brain go “no wait, toddler and baby won’t eat one and a half each, that’s wrong”. I panicked. I felt shame. I quickly devoured one roll and hid another in the bottom of my handbag to be disposed of later. I could not confess my error.

A few days later my husband proposed a picnic in the park. When I started piling bags by the front door to bring with us (nappy change bag, breast pump, cooler bag which contained 4 feeds worth of breast milk for a 3 hour outing, bag with various sunscreen and insect repellent, first aid bag, toys for toddler, picnic blanket), and then my husband announced we could only bring what could fit in buggy basket and what I could carry. So I loaded the buggy basket, picnic blanket and nappy change bag over one shoulder and bag with kids change of clothes on the other. I then slid the parasol – yes parasol – under the buggy bassinet, it protruded from the back and from the front bumping me in the leg with each step. We got 100 metres from our house when the parasol slid out onto the ground and my husband announced he would take it home, because I had put a hat on toddler, we were all wearing sunscreen and there were plenty of trees for shade. My whole body started to shake, I burst into tears, screamed and then stomped my feet in rage. I simply had to bring the parasol. Writing this now I cannot explain why it felt so important that I bring that parasol but at the time it felt like I was crumbling from the inside.

I felt a failure. I felt I was letting everybody down. I felt lost and alone. I felt I had given birth and in that moment been transported to a parallel universe where the ‘real’ me that I had replaced was so much smarter and competent than I was. I felt an impostor.

This episode prompted my husband to encourage me to get a referral for mental health support. I did go to NMH Holles St Mental Health department and chat with the staff. But I kept making excuses for my emotional outbursts and anxiety.

I refused to take medication for a number of months. I regret it. I have a thyroid condition and I take medication for it every day. My uncle is diabetic and takes medication for it every day. I had an illness and I refused to take medication that could have helped me. I am not alone in reacting this way. The mental health team I have since checked back in with confirm the majority of women downplay their symptoms and initially refuse medication. My postnatal anxiety was considered a ‘mild’ form.

Feelings of anxiety, overwhelm, apathy, sadness, depression, self-doubt, fatigue, worries, intrusive thoughts, negative thoughts, or panic are all common and can be managed then eased with appropriate support. Unfortunately not every woman suffering with a mental health illness will admit to it or seek help.

Women are now being asked specific questions about their mental health - as well as their physical health - at maternity hospital booking clinic appointments. Women can talk to their midwife and ask for support from the perinatal mental health midwife in their hospital if needed. Your GP and Public Health Nurse can also provide support and signposting to the most relevant service for each woman.

If help from the GP or PHN is not enough, your GP can refer you to a perinatal mental health service. A Specialist Perinatal Mental Health Service (SPMHS) will usually look after someone who has a more serious or complex mental health problem. So, not every woman with a mental health problem during pregnancy, or after their baby is born, will need this sort of service.

A survey of the rates of antenatal depression in the Irish Maternity Services showed that 16% of women in Ireland are at probable risk of depression during their pregnancy, which is one in six pregnant women. So the next time you are attending an Antenatal appointment have a look around the waiting room and reflect that 1 in 6 of those around you may develop mental health problems during their pregnancy or postpartum, and that person could be you.

A study identified women’s caring role as a potential barrier inhibiting discussion on mental health issues. Fears that women would misinterpret questions as a judgement of their mothering capacity could act as a barrier to some professionals offering support. Women who experience mental health difficulties may feel judged as mothers and be concerned about the removal of their children.

Researchers believe that despite more conversations around mental health taking place – which in turn help to break the stigma and silence that surround mental health problems – it is important to keep in mind that there are additional aspects of stigma for a mother who is experiencing a mental health problem. Women worry about how they will be perceived by their family and communities for experiencing a mental health problem during a time which society largely regards as a time of happiness and joy. Some women may even think that their ability as a mother will be questioned. This creates an additional barrier to mothers reaching out for support for their mental health.

The risk of a dad developing postnatal depression is up to five times higher if their partner is experiencing mental health difficulties. Some risk factors for postnatal depression are common to both women and men, including a shift in identity, sleep deprivation, changes in levels of social support and adjustments within the parents’ relationship. However, dads also report feeling excluded from the birthing journey, being ignored by healthcare professionals and worrying excessively about their job and financial stability. Furthermore they may not necessarily be able to access support from their own parents and family members, as mothers often can.

For all of these reasons, dads with postnatal depression typically report feeling overwhelmed or powerless, while they often refer to stigma or taboos in relation to their masculinity, all of which pose significant barriers to seeking help or even accepting that they are experiencing such distress. Many men describe the pressure they feel to be "strong" during this time and, therefore, when they experience anxiety or depression, they may feel like a failure, or ashamed, thereby compounding their distress.

Fathers can even develop Post Traumatic Stress Disorder if they witness their partner experiencing a difficult or traumatic birth. Furthermore, many fathers acknowledge that their primary role during the pre- and post-birth period is to support the mother and as a result, they often do not seek (or anticipate a need for) support for themselves and may choose instead to disregard their own emotions or anxieties. Not only will this take a toll on the father, but it often means that their relationship with their partner and the wider family may also be affected.

While recent years have seen an increasing interest in, and recognition of the importance of, pre- and postnatal depression and anxiety in dads, very little research is available on what types of psychosocial (or non-pharmacological) support fathers may specifically need to help support them through this period. Researchers have identified a need for accessible, dad-specific, support programmes which incorporate a group fitness or exercise component and which are used and recommended by other dads. When support is available, however, fathers are often apprehensive about engaging for fear they may be stigmatised.

Fathers play a crucial role in supporting both their partner and children during the postnatal period, but a significant proportion may be silently carrying the burden of their own mental distress during this time. It is important, therefore, that a 'two-parent' inclusive approach is adopted by health professionals to facilitate early recognition of symptoms, whilst there is also a need for a greater knowledge and awareness/recognition at a wider societal level to tackle the stigma surrounding postnatal mental health problems in men as part of the growing discourse around male mental health more generally.

The percentages of women and men suffering with perinatal mental health illness indicate that is common, but it is not yet talked about openly. It is of paramount importance to remove any sense of shame or failure that a new parents may feel. This can be achieved through normalising conversation around mental health disorders and their prevalence. Postpartum support can help as well as antenatal classes that discuss in greater depth realistic expectations of the postpartum experience and sometimes loneliness of postpartum.

In 2024 there were approximately 54,000 births in the Republic of Ireland.

Estimated number of women affected by perinatal mental illnesses in Ireland each year:

Adjustment disorders and distress - 20,133

Adjustment disorders and distress occur when a woman is unable to adjust or cope with an event such as pregnancy, birth or becoming a parent. A woman with these conditions will exhibit a distress reaction that lasts longer, or is more excessive than would normally be expected, but does not significantly impair normal function.

Rate: 150-300/1000 maternities

37%

Mild to moderate depressive illness and anxiety states - 10,066

Mild-moderate depressive illness includes symptoms such as persistent sadness, fatigue and a loss of interest and enjoyment in activities. It often co-occurs with anxiety, which may be experienced as distress, uncontrollable worries, panic or obsessive thoughts.

Rate: 100-150/1000 maternities

Post traumatic stress disorder (PTSD) - 2,013

PTSD is an anxiety disorder caused by very stressful, frightening or distressing events, which may be relived through intrusive, recurrent recollections, flashbacks and nightmares.

Rate: 30/1000 maternities

Severe depressive illness - 2,013

Severe depressive illness is the most serious form of depression, where symptoms are severe and persistent, and significantly impair a woman’s ability to function normally.

Rate: 30/1000 maternities

Chronic serious mental illness - 134

Chronic serious mental illnesses are longstanding mental illnesses, such as bipolar disorder or schizophrenia, which may be more likely to develop, recur or deteriorate in the perinatal period.

Rate: 2/1000 maternities

Postpartum Psychosis - 134

Postpartum psychosis is a severe mental illness that typically affects women in the weeks after giving birth, and causes symptoms such as confusion, delusions, paranoia and hallucinations.

Rate: 2/1000 maternities

At the moment, maternal healthcare stops at 6-weeks postpartum. But research shows that a substantial number of women are experiencing clinical-level symptoms of depression, anxiety and stress well beyond this period of service provision. Depression and stress symptoms measured the lowest during pregnancy but increased after birth at 3 months postpartum and were at the highest at 6 months postpartum. Depression and stress dropped a little at 9 months postpartum and then increased again at one year postpartum.

This means that women are not supported by a maternity care system that can detect and offer timely treatment to women who need it. Women who experience mental health problems in motherhood have to seek out treatment for themselves, and that can be a very difficult call for a woman to make. Women would really benefit from postpartum healthcare that can support them for longer.

The risk of a dad developing postnatal depression is up to five times higher if their partner is experiencing mental health difficulties. Dads with postnatal depression typically report feeling overwhelmed or powerless, while they often refer to stigma or taboos in relation to their masculinity, all of which pose significant barriers to seeking help or even accepting that they are experiencing such distress. Many men describe the pressure they feel to be "strong" during this time and, therefore, when they experience anxiety or depression, they may feel like a failure, or ashamed, thereby compounding their distress.

Furthermore, women birthing in Ireland have reported that their postpartum care is predominately infant-centred and does not facilitate opportunities for women to discuss their own physical or mental health. Continued postpartum contact is vital to ensure that women who develop symptoms beyond 6-week postpartum are identified and receive the support that they need to regain optimum health.

Therefore the current model of 6-week postpartum care in Ireland is insufficient to detect and provide adequate support for women’s mental health needs, with long-term implications for women and children.

Sources:

·      HSE Specialist Perinatal Mental Health Services Model of care for Ireland

·      Mind Mothers study - Perinatal mental health: an exploration of practices, policies, processes and education needs of midwives and nurses within maternity and primary care services in Ireland 

·      Reality of maternal mental health for first time mums in Ireland: study, Trinity’s School of Nursing and Midwifery