Perinatal mental health

Summary

Perinatal mental health encompasses mental health conditions occurring during pregnancy and the first 12 months postpartum, including depression, anxiety, psychosis, and trauma, representing a major complication requiring systematic screening and treatment.
Maternal mental wellness depends on creating safe, non-judgmental therapeutic environments, when to involve support systems through both emotional and practical assistance, and addressing often-overlooked concerns like birth trauma and postpartum anxiety.
For those wondering how to screen for perinatal depression, it involves using validated tools like the Edinburgh Postnatal Depression Scale (EPDS) and PHQ-9 at initial prenatal visits and throughout pregnancy, with scores of 13+ on EPDS or 10+ on PHQ-9 indicating likely depressive illness.
For those asking: ”What about medication during pregnancy?” answering this question requires balancing potential benefits against risks through shared decision-making, as evidence supports pharmacologic treatment for several perinatal mental health conditions despite historical concerns.
Private practice clinicians play crucial roles in screening, treatment, partner support, and recognizing that untreated perinatal mental illness constitutes an adverse childhood experience with long-term developmental impacts.

Perinatal mental health refers to mental health conditions that occur during pregnancy and in the postpartum period—specifically the first 12 months after delivery.

For mental health therapists and nurse practitioners working in private practice, understanding perinatal mental health and maternal mental wellness is essential, as perinatal mental illness represents a major complication of pregnancy and a leading cause of maternal morbidity and mortality in the United States.

Perinatal mental health encompasses screening and management of numerous conditions including depression, anxiety disorders, postpartum psychosis, baby blues, bipolar disorder, schizoaffective disorder, schizophrenia, borderline personality disorder, post-traumatic stress disorder, and obsessive-compulsive disorder.

Understanding perinatal mental health

Perinatal mood and anxiety disorders are common complications that occur during pregnancy or in the first 12 months after delivery.

Understanding risk factors helps clinicians identify clients who may benefit from enhanced monitoring and early intervention.

Key risk factors for perinatal mental illness include:

Personal psychiatric history: Previous episodes of depression, anxiety, or bipolar disorder significantly increase risk for perinatal mental health challenges.

Psychosocial stressors: Ongoing partner conflict, inadequate social support, and chronic life stressors contribute substantially to perinatal mental health difficulties.

Biological factors: Hormonal fluctuations, sleep deprivation, and inflammatory changes during and after pregnancy impact mental well-being.

Trauma history: Previous traumatic experiences, including prior birth trauma, increase vulnerability to perinatal mental health conditions.

Given the prevalence and serious consequences of untreated perinatal mental illness, systematic screening represents a critical component of comprehensive perinatal care and maternal mental wellness.

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How to screen for perinatal depression

It is recommended that clinicians screen for perinatal depression and anxiety at the initial prenatal visit, throughout each subsequent pregnancy office visit, and at postpartum visits using standardized, validated instruments.

Screening is crucial in identifying and treating individuals affected by perinatal mental health conditions.

Edinburgh Postnatal Depression Scale (EPDS)

The Edinburgh Postnatal Depression Scale (EPDS) is a 10-question tool specifically designed to identify clients at risk for perinatal depression.

The scale focuses on how the individual has been feeling during the preceding week.

Key features of the EPDS:

Scoring interpretation: Clients who score 13 or greater are likely experiencing depressive illness requiring further evaluation and intervention.

Focus and limitations: While useful for depression screening, the EPDS does not detect anxiety disorders, phobias, or personality disorders that may also require attention.

Widespread recommendation: The American Academy of Pediatrics and the United States Preventive Services Task Force recommend the EPDS for perinatal mental health screening.

Patient Health Questionnaire Depression Scale (PHQ-9)

An alternative to the Edinburgh Postnatal Depression Scale, the Patient Health Questionnaire Depression Scale (PHQ-9) is an extensively utilized depression screening tool used globally across a widespread range of medical conditions, clinical settings, and age ranges.

PHQ-9 scoring and interpretation:

Scoring system: The PHQ-9 scores each of the nine DSM criteria for depression from "0" (not at all) to "3" (nearly every day).

Cut-off scores: A PHQ-9 score of 10 or greater has 88% sensitivity and 88% specificity for major depression.

Severity ranges: Scores of 5, 10, 15, and 20 represent mild, moderate, moderately severe, and severe depression, respectively.

Both the EPDS and PHQ-9 are recommended by major medical organizations for how to screen for perinatal depression, giving clinicians flexibility to choose the tool that best fits their practice setting and patient population.

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What about medication during pregnancy?

When it comes to perinatal mental health, understanding the pros and cons of medication during pregnancy requires acknowledging both historical concerns and current evidence supporting pharmacologic treatment when clinically indicated.

Historical context and ongoing concerns

Ever since the thalidomide incident—when a medication prescribed for morning sickness in the 1950s-1960s caused severe birth defects—there has been understandable apprehension regarding medication use in pregnancy and potential fetal effects.

This historical trauma has created lasting hesitation among both patients and providers about using psychiatric medications during pregnancy, even when maternal mental illness poses significant risks.

Current evidence and clinical considerations

The critical question clinicians must address is whether the potential benefits of pharmacologic treatments for mental health disorders outweigh the potential harms.

Unfortunately, current clinical guidelines remain inconsistent, and there is a lack of consensus on best practices.

The medical evidence regarding pharmacologic mental health treatments in perinatal women has substantial limitations due to:

Lack of clinical trial data: Ethical concerns prevent randomized controlled trials of psychiatric medications in pregnant individuals.

Confounding observational data: Existing studies often cannot separate medication effects from the impacts of underlying untreated mental illness.

Individual variation: What works safely for one patient may not be appropriate for another based on specific circumstances.

Shared decision-making approach

Clients and clinicians should collaboratively review the risks and benefits of proposed pharmacologic treatment plans, along with an evaluation of the severity of the perinatal mental health disorder.

This shared decision-making process should consider:

Severity of mental illness: More severe conditions may warrant medication despite potential risks.

Previous medication response: Past treatment success or failure informs current decisions.

Patient preferences and values: Individual beliefs about medication use during pregnancy must be respected and incorporated.

Available evidence: Systematic reviews have found evidence of benefits for several pharmacologic treatments of anxiety, depression, bipolar disorder, and schizophrenia in perinatal mental health populations.

The decision about what about medication during pregnancy must be individualized, evidence-informed, and made collaboratively between clinician and patient, weighing the very real risks of untreated mental illness against potential medication concerns.

When to involve support systems

The effectiveness of perinatal mental health care depends on clinicians creating a safe, non-judgmental environment in which individuals feel respected and heard.

In this therapeutic space, patients are more likely to discuss their mental health issues and needs openly.

Types of support systems

Understanding when to involve support systems requires recognizing that patient support takes two essential forms:

Emotional support: Individuals or organizations provide emotional and psychological assistance, creating safe spaces where people feel secure sharing feelings and concerns without judgment.

Practical support: Friends, family members, and community members offer tangible resources and hands-on assistance with childcare, meals, household tasks, and daily responsibilities.

Both forms of support are crucial to proper perinatal mental health care and maternal mental wellness.

The initiation of support systems should be encouraged immediately for daily life balance, stress management, and maintenance of well-being.

Addressing barriers to seeking support

Some individuals with mental health difficulties may fear seeking support, which can cause further isolation and worsen their condition.

Common barriers include:

Stigma and shame: Concerns about being judged as inadequate or failing at parenthood.

Fear of consequences: Worries about child protective services involvement or custody concerns.

Cultural factors: Beliefs that discourage discussing mental health or accepting help outside the family.

Practical obstacles: Limited time, transportation challenges, or financial constraints.

Clinicians are in an excellent position to assist patients in identifying and connecting with individuals, peer support groups, and organizations they can seek support from.

This may include postpartum support groups, new parent communities, mental health services, and family resources.

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How to handle birth trauma

Giving birth is a meaningful, transformative, and potentially traumatic event that deserves clinical attention when it causes lasting distress.

Understanding birth trauma

Birth trauma is emotional distress or physical pain that occurs before, during, or after childbirth.

This experience is often unrecognized and untreated, as it's difficult to objectively measure an individual's birthing experience.

Signs of birth trauma include:

Psychological symptoms: Depression, anxiety, panic attacks, nightmares, flashbacks, and intrusive thoughts about the birth.

Avoidance behaviors: Difficulty discussing the birth, avoiding medical settings, or fear of future pregnancies.

Hyperarousal: Heightened startle response, difficulty sleeping, irritability, or hypervigilance.

Negative cognitions: Self-blame, guilt, or belief that one "failed" at childbirth.

Clinical implications and treatment

A traumatic birth can impact quality of life for days, months, or even years for anyone involved or present during the birthing process.

Birth trauma can lead to childbirth post-traumatic stress disorder (CB-PTSD) and has been shown to be a contributing factor to postpartum depression.

When considering how to handle birth trauma, key clinical approaches include:

Validation and psychoeducation: Affirming that birth trauma is real and not indicative of personal weakness or inadequacy.

Trauma-focused therapy: Evidence-based approaches like cognitive processing therapy (CPT), prolonged exposure (PE), or Eye Movement Desensitization and Reprocessing (EMDR) adapted for birth trauma.

Narrative processing: Helping clients construct coherent narratives of their birth experiences to integrate traumatic memories.

Partner and family involvement: Recognizing that partners and family members present at birth may also experience trauma requiring support.

One critical principle: Always trust and listen to your clients. If someone is harboring negative feelings from childbirth, they likely have experienced birth trauma regardless of whether the birth appeared "normal" to medical staff.

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What about postpartum anxiety

Evidence has shown that individuals in the perinatal and postpartum periods appear particularly vulnerable to anxiety disorders, yet postpartum anxiety often goes unrecognized compared to postpartum depression.

Causes and manifestations

Postpartum anxiety has been linked to the hormonal changes that occur after childbirth. Physiologic changes—including alterations in inflammatory mediators, hormones, and sleep patterns during and after pregnancy—may contribute to postpartum anxiety.

When addressing what about postpartum anxiety, clinicians should recognize diverse presentations:

Panic symptoms: Some individuals experience panic attacks with sudden onset of intense fear and physical symptoms.

Obsessive-compulsive symptoms: Others have intrusive, unwelcome thoughts (obsessions) that may be accompanied by compulsions—repetitive behaviors performed to relieve distress.

Generalized anxiety: Persistent, excessive worry about multiple concerns related to the baby's health, parenting competence, or family well-being.

Physical symptoms of postpartum anxiety

Physical manifestations can include:

Rapid heart rate and heart palpitations
Shortness of breath or feeling unable to catch one's breath
Dizziness or lightheadedness
Chest tightness or discomfort
Feelings of impending doom or loss of control
Nausea or gastrointestinal distress
Muscle tension and restlessness

Treatment approaches

Postpartum anxiety can be managed with psychological therapy, medication, or a combination of the two.

Management depends on several factors:

Severity of symptoms: Mild anxiety may respond to psychotherapy alone, while moderate to severe anxiety might benefit from combined treatment.

Patient preferences: Individual boundaries and preferences regarding treatment approaches must guide decisions.

Treatment goals: Collaborative goal-setting ensures interventions align with what matters most to the patient.

Evidence-based psychological treatments include cognitive-behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness-based interventions specifically adapted for postpartum anxiety and maternal mental wellness.

How to support partners

Supporting a partner's perinatal mental health is of the utmost importance, yet partners often feel helpless or uncertain about how to provide meaningful support.

Essential support strategies

Clinicians can guide partners on how to support maternal mental wellness through several key approaches:

Listen and share time: There are no perfect words when providing support. Simply being emotionally and physically present is the goal, with partners sharing time whenever possible to foster relationship development and connection.

Get informed: Everyone copes better when informed regarding health expectations and treatment options. Encourage partners to learn about perinatal mental health conditions and available treatments.

Seek professional help: Partners should not hesitate to involve mental health professionals when needed. This demonstrates strength and commitment rather than inadequacy.

Join support groups: Organizations and support groups specializing in perinatal mental health can provide valuable guidance for both patients and partners.

Setting realistic expectations

The goal of partner support isn't for someone to act a certain way or say certain things—it's about honesty, encouragement, and acknowledgment.

Partners should understand:

Validation over solutions: Sometimes listening without trying to "fix" things provides the most meaningful support.

Consistency matters: Regular check-ins and ongoing presence prove more helpful than sporadic intense involvement.

Self-care enables caregiving: Partners must maintain their own well-being to effectively support their loved one.

Accepting assistance

As encouraging healthy perinatal mental health can be a multifaceted process, accepting help is essential—and this applies to partners as well as patients.

Support doesn't need to be done alone or in isolation. W

hether it's a neighbor making dinner, a sibling providing childcare, or friends offering respite, accepting assistance during times of vulnerability is not only okay—it's necessary for maternal mental wellness and family thriving.

The long-term importance of perinatal mental health

Untreated perinatal mental illness is an adverse childhood experience (ACE) that can significantly impact a child's development and health throughout their life course.

The term "adverse childhood experiences" comes from the CDC-Kaiser Permanente Study conducted from 1995 to 1997, which became the largest body of research categorizing types of childhood trauma and understanding its long-term health impacts.

Research has established that exposure to maternal mental illness in early life can affect:

Attachment security

The parent-child bond may be disrupted by untreated mental illness, affecting the child's ability to form secure relationships.

Emotional regulation

Children may struggle with managing their own emotions when caregivers experience untreated mental health conditions.

Cognitive development

Depression and anxiety can interfere with responsive parenting practices that support optimal brain development.

Long-term health

ACEs, including exposure to parental mental illness, are associated with increased risk for chronic health conditions, mental health disorders, and substance use across the lifespan.

This reality underscores the critical importance of identifying and treating perinatal mental health conditions—not only for maternal well-being but also for the health and development of the next generation.

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Supporting maternal mental wellness in private practice

Perinatal mental health represents a critical area of focus for mental health therapists and nurse practitioners working in private practice.

By implementing systematic screening protocols, understanding treatment options including medication considerations, building robust support systems, addressing often-overlooked concerns like birth trauma and postpartum anxiety, and involving partners in care, clinicians can make profound differences in the lives of individuals and families during this vulnerable period.

The work of supporting maternal mental wellness extends beyond alleviating individual suffering—it prevents adverse childhood experiences, promotes healthy child development, and strengthens families for generations to come.

As private practice clinicians, you are uniquely positioned to provide the comprehensive, compassionate care that individuals experiencing perinatal mental health challenges deserve and need.

Sources

American Academy of Pediatrics. (n.d.). Perinatal mental health and social support. American College of Obstetricians and Gynecologists. (n.d.). Perinatal mental health.
Bhat, A., Nanda, A., Murphy, L., Ball, A. L., Fortney, J., & Katon, J. (2022). A systematic review of screening for perinatal depression and anxiety in community-based settings. Archives of Women's Mental Health, 25(1), 33-49.
Cleveland Clinic. (n.d.). Birth trauma.
Collier, S. (2021, July 20). Postpartum anxiety is invisible, but common and treatable. Harvard Health Blog.
Goulding, A., Metz, T. D., Middleton, J. C., Hoffman, M. C., Miller, E. S., Moore Simons, T. A., Stuebe, A., Viswanathan, M., & Gaynes, B. N. (2022). Pharmacologic treatment for perinatal mental health disorders. Obstetrics & Gynecology, 139(2), 297-303.
Johns Hopkins Medicine. (n.d.). Supporting a spouse through a health challenge.
Kendall-Tackett, K. A. (2024). Screening for perinatal depression: Barriers, guidelines, and measurement scales. Journal of Clinical Medicine, 13(21), 6511.
Kroenke, K., Spitzer, R. L., & Williams, J. B. W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of General Internal Medicine, 16(9), 606-613.
O'Hara, M. W., & Wisner, K. L. (2014). Perinatal mental illness: Definition, description and aetiology. Best Practice & Research Clinical Obstetrics & Gynaecology, 28(1), 3-12.
Wang, L., Kroenke, K., Stump, T. E., & Monahan, P. O. (2021). Screening for perinatal depression with the Patient Health Questionnaire Depression Scale (PHQ-9): A systematic review and meta-analysis. General Hospital Psychiatry, 68, 74-82.
World Health Organization. (2022, September 19). WHO guide for integration of perinatal mental health in maternal and child health services.
Zappas, M. P., Becker, K., & Walton-Moss, B. (2021). Postpartum anxiety. The Journal for Nurse Practitioners, 17(1), 60-64.

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