Do Postpartum Depression Symptoms Look Different in a Pandemic?

When you become a parent in the midst of a global pandemic, everything is new. Here's how to distinguish between the stress of 2020 and a perinatal mood and anxiety disorder (PMAD) and get the help you need.

An illustration of a sad woman sitting under a mobile with a bear during COVID.
Photo: Illustration: Caitlin-Marie Miner Ong

This past April, only a few weeks postpartum, my son's pediatrician handed me a print out of the Edinburgh Postnatal Depression Scale (EPDS). The screening tool, developed in Scotland in 1987, is 10 questions long and used around the world to detect a variety of perinatal mood and anxiety disorders (PMADs) such as postpartum depression or postpartum anxiety.

The form's prompts range from "I have been able to laugh and see the funny side of things" to "The thought of harming myself has occurred to me." Each answer is assigned a numerical value. The higher the score, the more likely the respondent is suffering from a PMAD.

Traditionally, it's considered the "gold standard" of postpartum screening tools since it screens for both anxiety and depression (and not just depression). It's used at doctor's offices and hospitals. Google even just launched a virtual EPDS: Search the term "postpartum depression" and the EPDS screener will pop up.

I'd been expecting the questionnaire: This was my third child and I had taken the EPDS at each of my postpartum follow-up appointments as well as at a few pediatric appointments over the years.

But this time, I found myself struggling to answer one of the questions, "I have looked forward with enjoyment to things as much as I ever did, rather less than I used to, definitely less than I used to, hardly at all."

I joked with my son's doctor: There wasn't actually anything on my schedule to look forward to. We were in the midst of the COVID-19 pandemic and everything had been canceled for the foreseeable future.

But I wasn't really joking. The truth was that I wasn't looking forward to anything. There wasn't anything to look forward to.

As I left the pediatrician's office, I wondered: Was the sadness and anxiety I had been feeling related to the current times, or was I suffering from a PMAD? And moreover, were these questions outdated?

Is the EPDS in Touch With Current Times?

The EPDS is far from perfect, explains Paige Bellenbaum, LMSW, founding director of The Motherhood Center. After all, experts know that women of color and women who come from low-income areas are at a higher risk of developing PMADs, but the EPDS doesn't always screen these mothers as effectively. Cumbersome wording makes it harder for women for whom English is a second language. "I cannot tell you how many women have taken [EPDS and have] especially gotten tripped up on question number six: 'things have been getting on top of me,'" says Bellenbaum. Someone who learned English as their second language may take that literally to mean having an object on top of them, she explains.

Additionally, Bellenbaum says that the questionnaire lacks culturally competent questions, especially when it comes to younger patients. She believes that using language that today's new and expecting moms can relate to—for example, updating question number six on the screening to something more in line with, "I have been feeling overwhelmed and unable to accomplish goals or tasks"—could go a long way toward uncovering PMAD symptoms.

But it's important to remember that the EPDS is the tool we have. And it's one that Bellenbaum—along with plenty of other mental health providers—wishes all health care providers would use.

After all, the American College of Obstetricians and Gynecologists recommends screening for PMADs during pregnancy and in the postpartum period, and the American Academy of Pediatrics has been endorsing the screening of new mothers for PMADs at the one, two, four, and six-month well visit since 2018, but not all providers screen.

I was lucky to be seen by both pediatricians and OB-GYNs who do. Bellenbaum says despite the recommendations it's not common practice.

So, right now, the issue isn't so much whether or not a screening method for PMADs is effective so much as it is about whether or not it's being used.

After all, even when it is used, patients aren't always honest with their responses. "People are so afraid of telling medical providers how they really feel—for fear of judgment, of the stigma that surrounds maternal mental health, and just mental health in general—with their greatest fear being potentially having a baby taken away," says Bellenbaum.

She’s not wrong. One of my biggest fears while filling out EPDS questionnaires over the years was that I would get something wrong and somehow out myself as being an unfit mother who should have her baby taken away.

More needs to be done both in ensuring that health care providers are screening, but also in educating women about the prevalence of perinatal mood and anxiety disorders—especially right now.

Why? Take one recent study of 900 women from this spring. It found over 40 percent of pregnant and postpartum women screened had an EPDS score of 13 or higher, indicating the presence of a PMAD. That's a stark contrast to the 15 to 20 percent figure that's often cited as it relates to PMAD incidence. The rise makes sense to Bellenbaum, who notes that PMAD risk factors such as isolation, lack of social support, and managing high levels of stress and anxiety are all things that the majority of Americans are facing right now.

PMAD or Pandemic? How to Get the Help You Need

The first month home with baby number three, I spent most of my time hiding out in my bedroom crying. I found myself prone to snapping at my children and my husband over minor infractions. Was I struggling with the effects of the pandemic or experiencing something more severe?

My score on the EPDS was on the higher end—but not high enough to indicate a clinical mental health disorder. Instead, it appeared that the weight of the pandemic was likely to blame.

But it was understandable that I couldn't tell the difference between a PMAD and pandemic stress. Right now, the lines can seem blurred. And while it's never your job to self-diagnose a mental health condition, being aware of signs and symptoms, educating those around you, and being an informed patient can go a long way toward getting the help you need.

If you're struggling, consider these four modern-day measures to help you identify what's going on.

paige bellenbaum, LMSW

Motherhood is romanticized. We're spoon-fed so many myths about what we think it's going to be like that when it's not like that—and it's almost always not—we think we're the only person who's going through it or that we're sucking at this and everybody else has it figured out."

— paige bellenbaum, LMSW

Speak up

If your doctor hasn't used the EPDS or a similar tool to help screen you for a PMAD, initiate the conversation, suggests Bellenbaum. Screenings help to diagnose PMADs and that's important. Receiving an actual diagnosis for a PMAD can keep you from feeling like your symptoms are simply something that you need to snap out of, explains Mary C. Kimmel, M.D., co-director of the Perinatal Psychiatry Program at the University of North Carolina at Chapel Hill.

Naming something "postpartum depression" or "postpartum anxiety" shows that there is a medical component that needs to be addressed, which can be helpful in encouraging moms—who are so guilty of putting themselves last—to seek help.

Do a feel-good check-in

There are a few ways to help sort out the difference between, "I can't look forward to things because I'm depressed" and "I can't look forward to things because things outside of my life are bad." For example, can you look forward to little things like a morning cup of coffee or watching your favorite show on Netflix?

If the answer is no, you may be suffering from PMAD, says Bellenbaum. Also, if you find that you're having a difficult time making decisions, feel as though by having a baby you made a big mistake, or if you've ever thought of giving your baby away, your depression is probably related to PMAD, she says. It's also worth noting that PMAD symptoms are different and last longer than the "baby blues," or the sad, anxious feelings many moms experience in the two weeks following delivery.

Keep an eye on COVID-related mental health symptoms

During the pandemic, your symptoms may have more of an anxious spin to them. Hyper-focusing on COVID-19 and your baby's health and safety or always Google "doomscrolling" are also common symptoms of PMADs right now, according to Bellenbaum. Other more timely symptoms: self-isolation, feeling completely alone, feeling irritable and angry that none of this is what you thought it was going to be like, and being sad or grieving the loss of what you thought motherhood in 2020 would look like.

Find pandemic-friendly support

"Motherhood is romanticized," says Bellenbaum. "We're spoon-fed so many myths about what we think it's going to be like that when it's not like that—and it's almost always not—we think we're the only person who's going through it or that we're sucking at this and everybody else has it figured out." This is all especially true now with reduced social contact, when new parents find themselves feeling exponentially more alone and frustrated with their perceived shortcomings.

The most important way to fight those feelings and treat PMADs? Figure out what support you need and make sure that you have access to it, says Dr. Kimmel.

In some cases, support is only a few clicks away. Organizations such as Postpartum Support International can connect you to trained perinatal mental health professionals (who you can see virtually!), support groups, and offer actionable steps you can take immediately at home.

Ultimately, remember: PMADs are highly treatable, but without treatment, they can continue well past your child's second or third birthday. "The sooner we identify a PMAD, the sooner we can treat it and a mom can return to her baseline and start to enjoy motherhood," says Bellenbaum. Yes, even in a once-in-a-lifetime (hopefully) pandemic.

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