By Navneet Patti, MD 
Psychiatrist, Psychiatric Center of Northwest Ohio 

When addressing mental health concerns during pregnancy and postpartum, clinicians often focus mainly on depressive disorders. While screening for depressive symptoms remains essential, it is crucial to recognize that other significant conditions—such as perinatal anxiety, obsessive-compulsive disorder (OCD) and postpartum psychosis—are frequently overlooked and left untreated. Data indicate that up to one in six women may experience OCD symptoms and one in eight may have anxiety symptoms during the peripartum period. 

Perinatal anxiety, OCD and postpartum psychosis can all go unnoticed, yet each can significantly affect both maternal and infant well-being. Feelings of shame related to these thoughts may lead to guilt, poor self-care, reduced adherence to medical recommendations, interpersonal conflicts within the family and difficulties in forming healthy attachments. 

Anxiety symptoms during the peripartum period often appear as numerous "what if" scenarios and are usually nonspecific. Physical and behavioral signs can include sleep disruption, increased heart rate, nausea, stomach aches, limited appetite, inability to relax, forgetfulness, irritability and a preoccupation with worst-case scenarios involving the newborn. Additionally, some women experience panic attacks for the first time during this period. 

OCD symptoms at this time often center on aggressive thoughts about harming the newborn or fears of contamination. These thoughts are typically ego-dystonic, meaning they are disturbing and unwanted for mothers. While such thoughts rarely lead to aggressive behavior toward the infant, they may be misunderstood as a desire to harm the baby. Intrusive thoughts can be extremely distressing, causing mothers to avoid routine caregiving, frequently seek reassurance from healthcare providers or compulsively check on their infants. 

Although rare, occurring in only one or two out of every 1,000 births, postpartum psychosis is the most severe form of postpartum psychiatric illness and constitutes a psychiatric emergency. Its presentation is often dramatic, with symptoms beginning as early as 48 to 72 hours after delivery. In most cases, it represents an episode of bipolar illness, resembling a rapidly evolving manic or mixed episode. Early signs include restlessness, irritability and insomnia, which may quickly escalate to severe disorganization, confusion and agitation. Delusional beliefs, typically focused on the infant, are common, and women may experience auditory hallucinations instructing them to harm themselves or their baby. 

It is essential to differentiate harm-related intrusive or obsessive thoughts (seen in OCD) from psychotic infanticidal ideas and delusions (seen in postpartum psychosis). Obsessive thoughts are ego-dystonic and horrifying to patients while psychotic delusions are not unwanted and may compel patients to act on them, leading to a higher risk of suicide and infanticide. 

Treatment depends on the severity of symptoms and may include both pharmacological and non-pharmacological approaches. Medications such as antidepressants, benzodiazepines and lithium can be used in combination with cognitive behavioral therapy to help alleviate these symptoms. However, antidepressants alone may be detrimental to patients with bipolar disorder and patients should not hesitate to disclose any significant mood changes or racing thoughts to providers. Mothers struggling with their mental health must seek proper diagnosis and treatment from a healthcare professional and understand that they are not alone. Perinatal and postpartum psychiatric disorders are common and support is available for those in need. 

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