What to know about postpartum depression and psychosis

When Andrea Clark went for her six-week postpartum checkup several years ago, she was too afraid to say how she was really feeling as a new mom. She couldn’t talk about her exhaustion, or how she felt like a failure because she couldn’t breastfeed. Or how she had shaken the bassinet when her son wouldn’t stop crying. 

“As depressed and as much as I was struggling, I still very much wanted to be a mom,” Clark said. “I didn’t feel like I was going to be given the benefit of the doubt and if I said no, ‘I need help, I’m not doing well’ […] I didn’t want him to be taken away from me.” 

This fear is one reason why postpartum mental health conditions go undetected, said Clark, who is now deputy CEO of Postpartum Support International and a member of the Perinatal Psychosis Task Force. That concern can be even stronger for mothers of color, who are more likely to encounter provider bias or Child Protective Services.

The issue of postpartum depression and psychosis drew national attention this summer due to Lindsay Clancy, a former labor and delivery nurse who was charged with strangling her three children and whose case ended in a mistrial earlier this month. Her attorney says she had postpartum psychosis. 

Clark spoke with Epicenter NYC about the warning signs of postpartum depression and psychosis and how to seek help or support someone with symptoms. 

Excerpts of the interview have been edited for length and clarity.

Epicenter NYC: What is the difference between the baby blues after pregnancy and postpartum depression? When should a parent consider reaching out for help?

Andrea Clark: The baby blues is typical. Probably up to 70 to 80% of women are going to experience some sort of mood change following delivery. So, in the first couple of weeks after delivery, women might feel like they are exceptionally tired. They might feel more irritable. They might feel sad or have trouble regulating their emotional response to things, and this is something that is completely normal.

What happens during pregnancy is there’s a hormonal shift and those shifts that help to introduce the feelings of joy and positivity and all of those things that their levels are elevated because we’re creating life inside of us. When we deliver, it’s almost like your body, your brain says, “We don’t need that much anymore.” And the levels drop really quickly.

It takes normally a couple of weeks for those levels to start to even back out again. So the first two weeks or so following delivery, it’s normal to feel some of those symptoms that feel like depressive symptoms — we call that baby blues. 

Epicenter NYC: And when is it not just the blues?

Andrea Clark: When those symptoms persist for longer than two to three weeks post-delivery, we’re edging into what we call postpartum depression.

So if you are feeling the lack of motivation to do things, you’ve lost interest in things that usually bring you pleasure, you’re finding it harder and harder to get out of bed, you have appetite changes or you find yourself crying or irritable, more irritable than normal — those things are considered indicators of postpartum depression. If you have had a history of depression prior to becoming pregnant, you’re much more likely to experience postpartum depression. 

But I would say that anytime you feel like, “I am just not feeling like myself,” and whether it’s the week after the baby was born, two weeks or six weeks, or six months, there is no wrong time to reach out and ask for support and help. A lot of times symptoms may not arise until six to seven weeks afterward. Be vigilant and mindful during that entire first year, or year and a half even, about how you’re feeling.

Epicenter NYC: Why can postpartum depression be hard to recognize? 

Andrea Clark: In the DSM-5, which is the mental health Bible [the main guide for mental health providers in the U.S.], there is no separate diagnosis for postpartum depression. It is usually major depressive disorder, or depression with peripartum onset, which means anytime during conception through first year post-delivery. So most of the symptoms are going to look substantially similar.

The things that become confusing for people: One is that everybody is tired. When you have a newborn, this is the hardest phase probably for a lot of people, of caregiving because your sleep pattern is being disrupted. There’s a natural disruption to the routine. Part of what happens is it’s hard to distinguish, ‘Is this just normal tiredness, adjusting to being a new parent, or is there something really going on with me?’ 

The other thing is there’s a narrative that we create about being a new parent that — even though we acknowledge that babies don’t sleep through the night, that new parents are going to be tired — the joy and the happiness of being a parent cancels out everything else.

So it’s not necessarily that these symptoms are going to be different, it’s that people don’t expect them a lot of times to show up during this period where you’re supposed to be so overwhelmingly happy and filled with joy that you have this new little life that you came for and this new family constellation. People don’t recognize that this could be more than just ‘I’m tired and adjusting to being a new parent,’ that there could be something else going on. And it’s okay for you not to feel happy and like yourself all the time.

Epicenter NYC: If you think you’re experiencing symptoms of postpartum depression but your provider doesn’t seem concerned, what could you do? 

Andrea Clark: During your perinatal wellness visit — because so many things are being checked on — the physical well-being is probably the primary concern for the obstetrician, the gynecologist at that point. Being vocal about your symptoms might feel unnatural and it sometimes feels unfair for us to have to be the ones to assert this aspect of our own well-being. Don’t be afraid, before you leave that appointment, to say, “Hey, I’ve been feeling a little more sad than usual. Yeah, the first two weeks were bad, but I still don’t feel quite like myself. I’ve been feeling a little lethargic. I’ve been wondering if I’m doing a good job at being a mom at all. I don’t know if I like it.” Even if you don’t want to disclose everything, but you want to say, “hey, is it normal for me to still be feeling a little bit more emotional or like I’m not quite feeling like myself, is that normal?”

Sometimes the pediatrician can also screen for these things with the parents, ‘cause you’re going with the baby more than you’re going to your own OB. You can ask, “Do they have any resources for new parents? Do they have any new parent support groups?”

And so if you feel like you’re not getting that response from your providers, there always are people who are trained and ready to help you that are just a phone call away. You can go to postpartum.net. We have virtual support groups. We have a helpline that will help you find resources in your area. There’s also the 24/7 National Maternal Mental Health hotline [1-833-TLC-MAMA] that you can call in over 60 languages. They’re trained, licensed, professional mental health professionals on the line.

Epicenter NYC: What are signs of postpartum depression that people in new parents’ lives might be able to more easily spot and how can they support?

Andrea Clark: If you have a relationship with the person who’s just given birth that precedes them giving birth or becoming pregnant and you’re starting to notice, ‘hey, they really don’t want to eat or hang out or they’re not laughing as much as they used to, or it’s taking a long time for her to get out of bed in the morning and I got up during the night and did all the feedings and she still doesn’t want to get up or she’s crying a lot’’ — if there’s a concern, ask them, “Is everything okay?” 

A lot of times, what we do as new moms is we figure we automatically need to know what to do with the baby and with ourselves. Like it’s supposed to be some automatic download. That’s not what happens. So the birthing person may not tell you, “yeah, I’m feeling weird; I’m not feeling like myself, I’m not feeling this happiness about being a parent.” They might put on the mask, pretend like everything is okay. 

The resources that we have, the maternal mental health hotline, the resources at PSI, are available to loved ones and friends if you’re concerned as well. So you can call and get advice about how to talk to your daughter, your friend, or your spouse, because you’re noticing they’re not acting like themselves. 

Epicenter NYC: What does treatment for postpartum depression look like?

Andrea Clark: For postpartum depression, there’s a range of treatment and it depends on the person. For some people medicine is going to be effective, but medicine in and of itself is not as effective as medicine plus some sort of therapeutic intervention.

Having a therapist to work with you one-on-one, usually cognitive behavioral therapy, is one of the most evidence-based, one of the gold standards for treatment for postpartum depression because it helps to challenge these automatic, negative thoughts and helps the person to rethink and replace those thoughts with thoughts that are going to lead toward more positive action.

One-on-one therapy is one option, but another is peer support. There are a lot of people who are looking for therapeutic services, and because of insurance and the shortage of providers, it’s not always possible to get right into a therapist who’s qualified to help you with these things.

But while you’re waiting, and even after you’ve found your therapist, virtual support groups like the ones that PSI offers can help. We offer over 50. If you’re only comfortable because your first language is Spanish and you want to be able to talk through what you’re going through in Spanish, there’s a support group for Spanish-speaking moms. There’s one for Desi moms or Southeast Asian moms, for Black moms. There’s one for dads. There’s one for people who this is their first pregnancy after they’ve had a loss. 

What we know about being in a supportive environment with those groups, which are led by people who have lived experience, is that you’re being led by somebody who’s walked through this and is on the other side of their healing journey. You’re walking alongside people who you can also, even if you don’t want to show up to the group and talk, sometimes just hear that somebody else is having the same kind of experience. It makes you feel less alone and makes it feel more valid, like, “What I was experiencing, this was a real thing. I’m not the only one that’s gone through this.” 

It can feel very isolating — whether it is depression, psychosis, anxiety or even the grief after a perinatal loss, you can feel very alone in that experience, but you’re not alone. You’re not to blame. You are doing a good job as a parent. You’re not to blame for how you’re feeling. You’re not to blame for the thoughts that you may be having. There are things biologically that are going on with you. With help you will be better. This is treatable. It’s temporary.

Epicenter NYC: Anything particularly helpful to say to someone who might feel ashamed or afraid of admitting that they’re struggling postpartum?

Andrea Clark: The best thing you can do is to assure them that they’re a good parent, that they’re doing a great job, because you never feel like you’re getting it right. Great parents are not perfect parents. Great parents are parents that show up and continue to try to get it right and to ask for help when they feel like they’re not getting it right. And tell them, “even if you feel like you can’t ask for help, seeing you continue to try lets me know that you’re a mom or a dad or a parent who loves that kid. So you’re doing a great job.”

Let them know that you’re here to listen and that if they don’t want to talk to you, you’ve identified some resources where they can actually talk to people who can identify with what they’re going through and help them walk through it and there’s no shame in asking for help.

Epicenter NYC: Anything not to say or do? 

Andrea Clark: One of the things we tell people as therapists not to do is when you notice somebody is struggling, don’t ask them “what can I do to help you?” or “call me if you need anything.” 

One of the things that helped to finally shake me out of the depression I was experiencing is my mom and sister, who came to stay with me for two weeks when my son was probably about seven weeks or so old, they walked in the door, and my sister said, “When the baby cries tonight, you stay asleep. Put some bottles in the fridge. I’m getting up to take care of the baby.” And at first I was like, “No, but you’re trying to say I can’t handle being a mom.” My sister had already had a child at that point and she’s like, “I’m not saying that. I’m saying that I know you need to sleep. So, I’ll take the feedings.”

From the time my mom got there, she was cooking dinner, so there were dinners for the weeks they were there and then she’s cooking more so she can put stuff in the freezer. Those kinds of things. Doing the baby’s and our laundry and restocking the diapers and making the Costco runs and making sure that I had fruit and other things that were fresh. 

These are things that you know the person is going to need, whether they tell you they need them or not, whether they feel like they’re going to ask you for help. Even if you don’t cook or don’t necessarily know what meals they’d like to eat, send a Grubhub gift card so that they don’t have to worry about cooking. If you live in a different state or don’t know if this person is primed for visitors yet, you can have Walmart, Target, whomever deliver a box of diapers.

But at least having those things that you know a new family is going to need takes a level of the worry off and lets somebody know that you’re here. Everybody wants to come over and see the baby or hold the baby, and everybody forgets about the mom’s needs or expects that you’re going to pick up these things that you have to do now that you’re a mom. You’ve got to do extra laundry and extra shopping and all these things. Take some of those things off of their plate, even if you are just sending a delivery or a gift card.

Epicenter NYC: What’s the link between helping take care of those basic physical needs and postpartum depression?

Andrea Clark: Part of what happens when a lot of women experience depression is that overwhelm can play a huge part in continuing those depressive symptoms. If you’re already feeling like, I don’t know why I’m having trouble getting out of bed or why I’m sleeping so much, thinking about all the daily tasks that have to be done to keep the household moving can add to that sense of overwhelm. It makes you feel like you’re never going to get out of this pit. There’s always something that you have to do, and you already don’t even feel like going to brush your teeth.

So list some things and give them some options you can do to help. Because then it feels like, ‘oh, that’s one less thing I have to think about and one less thing that makes it feel like I am so underneath my feelings already that I can’t take care of the basic needs of myself and my family.’ Those add to a feeling of ineffectiveness if you feel like you can’t do the basic things to take care of yourself.

Epicenter NYC: Could you distinguish between postpartum depression and postpartum psychosis? 

Andrea Clark: Postpartum psychosis is a very acute postpartum condition. It’s very serious. It’s a medical emergency.

When someone is experiencing postpartum psychosis, they’re having a break with reality. They’re usually marked by delusions, hallucinations and those kinds of things. They’re hearing or seeing things that may not be there or even physically feeling things that may not be there. They might feel like they’re covered in spiders or feel like they’re wet. It’s very real to the person, but it cannot be perceived by anybody else. And so they’re having a break with reality.

One in four women who experience psychosis, a lot of times leads to harming themselves or their children. This is why we say it’s an emergency. It’s something that can come on very suddenly. If you have a history of depression or anxiety before pregnancy, you’re more likely to have postpartum psychosis, but also more likely to have any of the range of postpartum mental health conditions.

Epicenter NYC: What are the warning signs of postpartum psychosis that people close to them should know? What should they do?

If the person is expressing that they’re seeing or hearing things that feel concerning, like you don’t see or hear those things, that is one possible sign. If they’re talking very fast or seem very manic and you can’t get them to calm down, or it feels like the speech is irrational, that’s another presentation of signs. Sometimes it might almost seem like the person may be catatonic. Like you’re talking to them or they’re sitting but there’s a glaze over them, like whatever you’re saying is not penetrating. Those are definitely some signs. If they have expressed that they want to hurt themselves or they’re having these scary thoughts about hurting themselves or their children, you need to call 988.

The reason we say 988, the national crisis hotline, and not 911, is because a lot of times emergency services and emergency rooms are not as equipped to handle people in this kind of crisis. Meanwhile, the crisis hotline will steer you toward resources where you can get somebody immediate help for this particular kind of crisis.

Epicenter NYC: Given the recent national conversation around the Lindsay Clancy case, what do you wish more people could better understand about postpartum psychosis? 

Andrea Clark: We need people to better understand that there are a range of prenatal mood disorders or postpartum mood disorders. We talk about depression all the time. Some people develop postpartum anxiety, postpartum obsessive-compulsive disorder, postpartum rage and then postpartum psychosis, which is the least common, probably one in between one and two in every 1,000 women will experience postpartum psychosis. A lot of what I’ve heard is people conflating all of these conditions into one. 

Postpartum psychosis is a different, more intense and more acute postpartum mental health condition. You don’t have to ever have experienced an episode of psychosis before this. It can come on suddenly, usually within a few weeks of giving birth, but there are women who have been six months postpartum and had these sudden-onset hallucinations or delusions or thoughts that tell them that they have to harm themselves in order to protect their children or they have to harm their children in order to protect their children from some other force.

It can come out of nowhere, seemingly nowhere. But it is not the same as postpartum depression. They’re related but they’re distinct mental health conditions, and one in particular is considered a medical emergency. None of these things are character flaws, none of them are moral failings on the part of the individual. It is an illness.

Epicenter NYC: You mentioned some families may be concerned that, if they seek out emergency psychiatric care, that will result in the parent and the baby being separated. What would you say to someone who has that fear? 

Andrea Clark: That is a legitimate fear. This is why we encourage you to use the resources that are specifically directed for people in these kinds of mental health crises. 988 is the national crisis line, so start there. The initial response won’t necessarily be “we need to separate this unfit mother and take the child away from them.”

Also, if you’re able to go in and receive emergency crisis care, if you have supportive friends or family, have someone go with you. Have someone walk alongside you. Don’t be afraid to enlist your support system in helping you get the help that you need. You’re going to have to have somebody who can talk about your baseline, what you were like yesterday and what they see as the difference between what’s going on with you today and what happened yesterday. Somebody that can continue to be your voice and be in your corner when you feel like you’re not or that people may not listen to you.