Postpartum Depression and Anxiety
Tools and Strategies to Combat Peripartum and Postpartum Depression and Anxiety in Working Mothers
Throughout their lifetimes, women are at a greater risk than men for developing certain psychiatric disorders, including major depression and generalized anxiety disorder (Kessler, 2003; Wittchen, 2002). The first year after childbirth (the postpartum period), as well as the short period of time before and immediately after delivery (the peripartum period), can be a particularly vulnerable time when mothers often experience massive biological, emotional, financial, and social changes. Consequently, these are periods when some women can be at an increased risk for developing a mental disorder, particularly depression and anxiety (Ross & McLean, 2006; Vesga-López et al., 2008). If left untreated, peripartum or postpartum mental distress can adversely influence the child’s cognitive and language development, mother–infant attachment, and maternal health and quality of life (Arteche et al., 2011; Henrichs et al., 2010).
Given that a majority of women of childbearing age in the United States are now employed outside the home (U.S. Department of Labor 2015), it is important to recognize the impact of peripartum or postpartum depression (PPD) and anxiety (PPA) on occupational outcomes. There are numerous ways in which human resources personnel, benefit directors, and supervisors can assist in mitigating the negative effects of postpartum distress in working mothers that, in turn, will help optimize their company’s workforce, employee well-being, and labor productivity. Supportive work environments can also offer a strategy to build loyalty, retention, and trust among valued employees, helping to set a company apart from others as an employer of choice.
A new federal initiative called Moms’ Mental Health Matters (MMHM) provides free educational content and resources that can be utilized in the workplace to support employees during this critical time in their lives.
Human resources personnel, benefit directors, and supervisors can assist in mitigating the negative effects of postpartum distress and help optimize their company’s workforce, employee well-being, and labor productivity. Supportive work environments also offer a strategy that helps to set a company apart from others as an employer of choice.
Peripartum Depression, PPD, and Anxiety
Peripartum depression and PPD are the most common mental disorders experienced after childbirth, occurring in approximately 10%–15% of, or about 1 in 7, women (Sit & Wisner, 2009). More than just the typical “baby blues,” peripartum depression and PPD can be debilitating, and they share symptoms similar to those of major depressive disorder, including but not limited to:
An excessively sad mood,
An inability to derive pleasure from activities one previously enjoyed (e.g., spending time with friends or engaging in leisure activities),
Chronic difficulties in sleep and/or appetite,
Feeling guilty or worthless,
Low energy, and
Thoughts of hurting oneself (American Psychiatric Association [APA], 2013).
The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), which provides the diagnostic criteria of all psychiatric disorders recognized by the U.S. healthcare system, describes a specific type of major depressive disorder, as well as a type of major depressive episode, that occurs during pregnancy or within 4 weeks after delivery, called major depression with peripartum onset (APA, 2013). The addition of the peripartum onset specifier is intended to call attention to the importance of diagnosing and treating depression during as well as after pregnancy.
“Half of all episodes of postpartum depression begin antenatally, and a lot of women feel even greater discomfort talking about depression when pregnant because of the stigma around it,” says Kimberly Yonkers, MD, professor of psychiatry at Yale School of Public Health and member of the DSM-5 workgroup that developed the peripartum specifier. “Postpartum depression is a bit more ‘accepted’ than depression in pregnancy, but we don’t want to miss the people who are depressed and pregnant.”
While most women will not experience PPD, mothers at greatest risk include those with a history of depression, substance use problems, increased life stress, low socioeconomic status, lack of social support, single status, and older age (over 40 years old) (APA, 2013; Goyal, Gay, & Lee, 2010).
Like PPD, anxiety disorders, including generalized anxiety disorder and obsessive–compulsive disorder, during pregnancy or following childbirth can occur in some women (Fairbrother, Janssen, Antony, Tucker, & Young, 2016; Miller, Chu, Gollan, & Gossett, 2013). Generalized anxiety refers to excessive, uncontrollable worry about a number of events or activities that is present more often than not for at least 6 months. It also can involve restlessness, fatigue, and difficulty concentrating. Obsessive–compulsive disorder is a type of anxiety disorder in which individuals experience unwanted, intrusive, and frequent thoughts or feelings (e.g., constantly worrying about the baby) or behaviors that they feel compelled to perform to reduce anxiety (e.g., repeatedly checking on the baby during sleep). The occurrence of any anxiety disorder during the perinatal period was recently reported to be about 17% (Fairbrother et al., 2016), but other estimates have fluctuated widely, from as low as 2.6% to as high as 39% (Leach, Poyser, & Fairweather-Schmidt, 2015).
Compared to depression, PPA is understudied and under-diagnosed (Miller et al., 2013; Ross & McLean, 2006). Risk factors for PPA are not as well known as those for depression but likely include pre-existing anxiety, co-occurring PPD, younger maternal age, premature delivery, and having a negative pregnancy experience in general (House et al., 2016; Miller, Hoxha, Wisner, & Gossett, 2015).
Effective treatments for both PPD and PPA are available in the form of cognitive–behavioral therapy and medication (American College of Obstetricians and Gynecologists, 2009). However, the under-recognition of symptoms and failure by doctors to regularly screen new mothers and pregnant women can lead to reduced treatment and poorer recovery of symptoms (Gjerdingen & Yawn, 2007). The APA guidelines for the treatment of patients with major depressive disorder recommends that, for women who are pregnant, planning to become pregnant, or breastfeeding, psychotherapy without medication should be considered as a first-line treatment in cases in which the depression or anxiety is mild, whereas antidepressant therapy should be considered more strongly as a primary treatment for moderate and severe cases of depression or anxiety (APA, 2010).
Antidepressant therapy for depression or anxiety during pregnancy is a controversial issue because of conflicting evidence about safety concerns to the developing fetus. Evidence suggesting a risk of birth defects associated with antidepressant use, especially during the first trimester, is inconsistent and often comes from small samples of participants or poorly designed studies (Byatt et al., 2013). What risks do exist appear to be very low. One of the more consistent findings pertains to an increased chance of cardiac deformities with the use of paroxetine (Paxil) in early pregnancy, but not all studies have found this effect (Byatt et al., 2013). There is no consistent evidence that antidepressants during pregnancy significantly increase the risk of premature delivery, low birth weight, persistent pulmonary hypertension of the newborn, autism spectrum disorder, or long-term cognitive and behavior problems in children (Robinson, 2015).
For women experiencing peripartum or postpartum disorders, antidepressant use appears effective and safe while breastfeeding, although long-term effects have not been studied and are unknown (APA, 2010). The risk of exposure of antidepressants to infants through breast milk is dramatically lower than their risk of exposure while in utero.
Although much of the data suggests that perinatal antidepressant use is likely safe, many women understandably feel concerned about taking these drugs while pregnant or breastfeeding. Mothers and mothers-to-be should talk to their healthcare providers, and ideally to a psychiatrist, about weighing any potential negative consequences of antidepressant use against the strong evidence on the known detrimental effects of untreated maternal depression or anxiety on the health and functioning of the child and the mother (including the risk of maternal suicide).
For more information about the use of depression and anxiety medications during and after pregnancy, visit the Organization of Teratology Information Specialists website.
Tips For Employers
Employer Engagement: Recommendations to Reduce Risk
Work participation allows mothers to experience healthy self-esteem, increased social support, and greater financial resources. However, the transition back to employment after childbirth can be fraught with stress, confusion, and questions—all of which only compound an already stressful time and increases the likelihood of PPD or PPA in vulnerable women. Businesses serve as a powerful point of contact in helping expectant and new mothers stave off mental distress. Potential strategies are numerous and can include the following:
Know what to look for: Do not assume that a woman with peripartum or postpartum distress will actively seek help if needed. Women may avoid disclosing symptoms to their doctors out of fear of stigma, being judged as an “unfit” mother, or having their child removed from the home (Chew-Graham, Sharp, Chamberlain, Folkes, & Turner, 2009). Similarly, they may worry that divulging their symptoms to employers could lead to repercussions at work, such as demotion or removal from projects and assignments (Selix & Goyal, 2015). Referral to the company’s employee assistance program (EAP) can increase the chances of all mothers and mothers-to-be receiving proper screening, diagnosis, and psychiatric care as needed.
Do not assume that a pregnant woman or new mother will develop depression or anxiety. Many women will maintain good mental health throughout their pregnancy and after childbirth. A woman’s reproductive status does not, in and of itself, make her more vulnerable to depression or anxiety. There are multiple factors that can lead to depression and anxiety, and employers should not make assumptions about an employee’s mental health based solely on her childbearing status.
Help promote earlier screening: Timely identification of depression and anxiety can lead to earlier treatment and better outcomes, but maternal screening and treatment referral for PPD and PPA are not standard practices during many healthcare visits (National Institute for Health Care Management, 2010). Ensure that EAPs have access to brief screens. Benefit directors can ask their healthcare plans to encourage providers to engage in screening and can ensure that plans include coverage of well-baby and well-child visits, as these have been shown to be useful in detecting maternal depression (Gjerdingen & Yawn, 2007). Indeed, the American Academy of Pediatrics recommends that pediatricians screen mothers for PPD at the child’s 1-, 2-, and 4-month clinic visits (Earls & the Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics, 2010). The American College of Obstetricians and Gynecologists Committee on Obstetric Practice (2015), as well as Siu and the U.S. Preventive Services Task Force (2016), also recommend screening for maternal depression and anxiety symptoms at least once during the peripartum and postpartum periods.
Information is key: Employers have ample opportunities to supply working mothers with much-needed information about peripartum and postpartum distress but should not wait until after delivery to provide these resources.
Once an employee has notified her supervisors that she is pregnant, information about mental health concerns can potentially be provided:
During human resources–employee meetings on coordination/continuation of benefits and leave options;
When an employee is completing maternity leave/disability leave or return-to-work paperwork;
Online, through the company’s intranet (this information should be placed in proximity to the company’s leave policy for ease of location);
Through informational handouts in the company’s lactation room;
During occupational services, such as wellness fairs and flu-shot clinics; and
On hand with EAPs for use during referrals for pregnancy-related distress
Human resources and benefit managers should consider including a visiting nurse program with the company’s maternity leave package to ensure that new mothers are preemptively educated on risks, symptoms, and treatments for mental disorders. This is also an opportune time for employers to promote the range of services they offer to support employees’ families during maternity leave, including services offered through the EAP. Such services could include information resources to help identify local child care programs, financial management resources, and the availability of company policies that promote flexible work environments, such as teleworking, flex scheduling, and job sharing.
One example of a comprehensive resource that companies can take advantage of is the MMHM initiative from the National Child & Maternal Health Education Program (NCMHEP), a national education program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The MMHM initiative offers a wide range of free education materials for healthcare providers, pregnant women, and new mothers concerning perinatal depression and anxiety. These include informational posters, note pads, and postcards (available in English and Spanish) designed to encourage awareness of symptoms and help-seeking.
“It is so important that we recognize the value of educating women and providers on these illnesses,” says Ranna Parekh, MD, MPH, of the American Psychiatric Association, one of more than 30 healthcare provider associations, federal agencies, and nonprofit maternal and child health organizations represented on the NCMHEP Coordinating Committee. “Without awareness of the seriousness of the symptoms, many women may dismiss their struggles as a normal part of pregnancy and childbirth and may suffer in silence instead of seeking treatment. And, unfortunately, physicians too might make this mistake and miss the opportunity to provide much-needed care. Education can lead to better outcomes for both a woman and her baby.”
Employers can readily share MMHM content with their company by ordering and distributing hard-copy handouts or by sharing the program’s URL, https://www.nichd.nih.gov/MaternalMentalHealth.
Make sure employees know their rights: Not all working mothers are aware of the rights afforded them by the U.S. Equal Employment Opportunity Commission (EEOC). According to the EEOC (2008), companies with more than 15 employees are required to comply with the 1978 Pregnancy Discrimination Act and the Americans with Disabilities Act (ADA). Under these, employers must make the same allowances, such as extended unpaid leave or workplace accommodations, to women with pregnancy-related disabilities as they do to employees with other ADA-covered disabilities. Reassure working mothers that they cannot be terminated, demoted, or denied promotion for experiencing a peripartum or postpartum mental illness (EEOC v. The Lash Group, Inc., 2014). Education about the terms of the Family Medical Leave Act should extend to all employees, not just pregnant women, and should include the length of time covered (up to 12 weeks unpaid) and eligibility (i.e., an employee must have worked for the company for 1 year and at least 1,250 hours within a year).
Calculate the feasibility of providing extended, or even paid, maternity leave: Research has found an association between longer maternity leave and a lowered risk of PPD, with women taking less than 6 months of leave being at an increased risk for the disorder (Chatterji & Markowitz, 2004; Dagher, McGovern, & Dowd, 2014). However, an extension might not be a realistic option for women who are taking unpaid leave, particularly if they are the sole wage earner in their household.
Only 12% of U.S. private companies offer paid parental leave, and there is a misperception that only large tech outfits and Fortune 500 companies can afford to do so. However, many businesses may be able to extend this privilege without breaking their bottom line. A recent analysis of the state-mandated paid leave programs in New Jersey and California found that paid leave financed by payroll deductions are relatively inexpensive, costing individual employees approximately $30 a year—less than $1 a week. The states have also reported that the programs tended to have either a positive effect or no impact whatsoever on outcomes such as profitability, performance, productivity, turnover, and employee morale (Devlin, 2015). Despite any lingering reluctance, some businesses may be forced to contemplate paid maternity leave in the near future: although only four states currently have such legislation (California, New Jersey, Rhode Island, and New York), 18 are reviewing their laws in consideration of adopting similar mandates (Duncan, 2016).
Time for a culture change? Rapid changes in the modern work environment, including the proliferation of computer technology and the United States transitioning from a manufacturing-based economy to a service-based one, have led to longer work hours, more shift work, and greater job complexity. Modifications that help mothers feel less stressed about keeping pace with workload demands and maintain better work–life balance bode well for recovery. For instance, allowing new mothers to work day shifts rather than night shifts helps them establish regular feeding and sleep–wake routines with newborns (Selix & Goyal, 2015) and optimize their own sleeping patterns as well. Also, many child care programs will not enroll children who are not toilet trained—meaning that women with infants have fewer options for child care, especially if they lack a partner or family members to help provide support. Permitting flexible schedules or teleworking can be especially helpful in such situations.
Postpartum depression has been linked to a number of job characteristics, including a more taxing workload, lower levels of employee perceived control over work and family life, greater job insecurity, and less scheduling autonomy and job flexibility (Cooklin, Canterford, Strazdins, & Nicholson, 2011; Dagher et al., 2009). Companies should reflect on the degree to which such factors can be ameliorated so as to give workers more freedom.
“A lot of women want to work, but they need the infrastructure that will allow them to take care of themselves, their family, and do the work they need to do,” says Dr. Yonkers. “Stress can increase the risk of depression, and employers allowing for even some degree of flexibility can go a long way.”
Finally, workplace social support has been shown to buffer against PPD (Dagher et al., 2009). Employers can assist by cultivating an attitude of acceptance and empathy, rather than one of judgment, about peripartum and postpartum distress. Work-based support groups can provide education and coping techniques while giving working mothers struggling with psychiatric symptoms a place to feel validated.
Depression and anxiety are frequently termed invisible diseases because their presence isn’t always readily apparent. Proactive employer engagement is crucial to reaching employees with PPD or PPA with education and destigmatizing efforts. It is also important to ensure that health plans have adequate access to mental health resources and treatment. Such actions not only help protect against operational costs and productivity losses, but they can also go a long way toward protecting the company’s most valuable asset—its employees.
Know Your Terms
Prenatal or Antenatal: This refers to the time period before birth, spanning the entire gestation period from conception to delivery.
Perinatal: This refers to the specific time period ranging from shortly before birth to shortly after birth. The definition varies somewhat from country to country, based on legal definitions of stillbirth and perinatal mortality. The World Health Organization specifically defines perinatal as the 22 weeks after gestation (about 5 months into pregnancy) through 1 week after delivery.
Postnatal: This refers to the time period after birth.
Emily A. Kuhl, Ph.D., owner and operator of Right Brain/Left Brain, LLC, is a consultant to the Partnership for Workplace Mental Health and a medical writer and editor in the Washington, D.C., area.