With heightened attention on postpartum depression, anxiety, and psychosis, a critical truth has been missed: A significant percentage of “postpartum” mental health disorders actually begin in pregnancy.

Often termed PMADs, Perinatal Mood and Anxiety Disorders encompass depressive, anxiety, and bipolar disorders. (The latter is often linked to postpartum psychosis—a rare and poorly treated variant.) The perinatal or peripartum period means “surrounding birth,” and includes the entire pregnancy and year after.

Research suggests that a third of perinatal depression cases begin during pregnancy. Anxiety disorder symptoms during early pregnancy are actually more prevalent than postpartum, with a quarter of pregnant women experiencing anxiety in early pregnancy, dropping to 20 percent during the remaining peripartum. Perinatal obsessive-compulsive disorder (OCD) is experienced by about 8 percent of women during pregnancy, and about twice that number experience it postpartum. New-onset bipolar is rare in the peripartum period, but over 50 percent of women who have bipolar before pregnancy experience at least one episode peri-partally.

Women and their loved ones need to be aware of the risk of early-onset PMADs. Frequently, women have been struggling with anxiety, depression, OCD, or bipolar symptoms for weeks or months before birth, but no one has inquired and women may feel anxious or embarrassed to mention them.

Often, mild PMADs can be treated with individual or group psychotherapy and lifestyle changes like sleep improvement, stress reduction, and social support. But a large proportion of women experiencing PMADs have moderate-to-severe symptoms requiring medication, which many fear or avoid, but shouldn’t because medication saves lives. In the United States alone, the largest causes of maternal death—20 percent—are suicide or overdose linked to PMADs.

Here’s what can help you or a woman you love get the treatment needed:

• Weigh risks and benefits. For moderate-to-severe PMADs, the benefits of medication have been shown to outweigh risks. Women who take perinatal medication for PMADs experience similar rates of miscarriage, birth defects, birth complications, and infant problems as women who don’t have PMADs. But women with moderate-to-severe PMADs who forego medication experience greater rates of miscarriage and infant and maternal complications including preterm birth, c-sections, low birth weight, preeclampsia, and infant/child developmental and behavioral disorders. Untreated PMADs are not benign. Mothers deserve treatment and needn’t think they’re “helping” their baby by avoiding medication.
• You deserve a specialist. If you have a history of psychiatric disorders, you hopefully have a psychiatric prescriber you trust and who feels comfortable treating people in pregnancy. If they don’t, you can ask them to consult with a prescriber who specializes in PMADs, or to send you to someone who does, at least for one visit. If you have never seen a psychiatric prescriber, you can find one through the Psychology Today directory where you can filter for psychiatrists—including psychiatric nurse practitioners—as well as insurance, perinatal conditions, etc. If you live far from a specialist, telehealth can often work just as well.
• Use what’s worked. Women often worry that “the only medication that’s worked” is not safe to take in pregnancy. It’s true that we try to avoid changing medications in pregnancy—a good reason to seek a specialist before getting pregnant, if possible, to discuss these issues. But even more important than not changing meds in pregnancy are individual circumstances. For instance, although SSRIs have been shown to be largely safe in pregnancy, maybe you’re tried several and they’ve never worked for you. Staying on an antidepressant (or other medication) that keeps you stable and well, yet has less, but generally reassuring, pregnancy data, is often more important than using the most studied medication for your condition. A specialist should be familiar with this data and can help you decide what’s best for you.
• Optimize the lowest effective dose. People often try to decrease dosages of medication in pregnancy, but this can leave them vulnerable to effects of the medication and effects of “breakthrough” PMAD symptoms emerging due to taking an inadequate dose. The goal is to feel few or no symptoms of PMADs in pregnancy and beyond. Skimping on meds that could help doesn’t do a woman or her pregnancy any good. Furthermore, taking too little of one med may mean you require another, and we try to simplify number of medications perinatally.
• Expect dosages to increase in pregnancy, especially during the last trimester. In pregnancy, your blood volume increases by up to half again as much as when you’re not pregnant. Your entire body is working hard, and as part of that, you metabolize medications faster, clearing them more quickly from your system. In virtually all cases, this means medication dosages need to increase during or even before the third trimester. These higher doses are often maintained postpartum, especially when lactating, which further increases metabolism.

If you’re pregnant or even considering pregnancy and are also experiencing anxiety, depression, or bipolar symptoms, talk to your provider and find the help you need.

Learn more about psychiatric disorders during pregnancy, and medications during pregnancy, so you’re primed with knowledge. You can even help women following in your footsteps by signing up for the national pregnancy medication registry and contributing to improved medication knowledge for all women, long into the future.