After our first daughter was born, I was shocked to learn we were actually coming home with a baby. Sounds ridiculous, but I’d planned all the way up through the birth part and not much after. During pregnancy, I was diligent about knowing everything about my baby’s development, down to her exact gestational age. I was not diligent about thinking forward to postpartum. It was all supposed to be bliss, right?
Pretty quickly, I started to show symptoms of what I now know was postpartum anxiety. I’m embarrassed to admit that, even as a mental health therapist, I didn’t recognize it. For me, it didn’t look or sound like fear. It mostly looked like unadulterated rage and a lot of rules: We have to do this in exactly this way, at exactly this time. At my six-week appointment, I filled out the Edinburgh Postnatal Depression Scale (EPDS), was asked if I was depressed, and was offered medication. We didn’t go over my answers or talk about anxiety. It wasn’t until I emerged from what I call the anxiety cloud that I realized what had been going on. Until that point, I’d assumed everyone felt the way I did and was just handling it better.
Fast-forward to our second baby. By then, I’d spent about a year training in maternal mental health, and my husband and I had talked about what we’d do if some of those familiar patterns showed up again. As soon as he saw a glimmer of them, he reached out to our doula and my midwife. We got support much sooner, and I didn’t have to rely so much on my less-than-functional anxiety strategies. You know, like controlling everyone and everything and yelling at everyone.
So… you’re pregnant now, and you’re feeling good.
Do you really need a postpartum mental health plan?
My answer is yes.
Even if you’re feeling good now, it helps to talk about what you’ll do if you start to feel less like yourself. If you’ve had depression, anxiety, or a difficult postpartum experience before, it’s especially worth having that conversation with your care team while you’re feeling well. You might never need to use the plan. If you do, you’ll have somewhere to start.
Start with one conversation
Sit down with your partner or someone you trust and talk through three questions:
What will be the signs that I’m starting to struggle? You may know your own warning signs and get your partners perspective as well. Maybe you stop texting people back or spend the whole evening checking and rechecking things. For me, it was getting rigid about small decisions and feeling furious when anyone deviated from my plan.
Who would I/we want to call? Pick a person or providers office now: your therapist, midwife, OB, or prescribing clinician. Find out how to reach them between appointments. Establishing care before you need it is valuable. Look around in your area for a provider that feels like a good fit and make that connection now. That way you’re not starting from scratch on a hard day.
What could you do to make that easier? Maybe you want your support person/people to tell you what they’ve noticed, sit with you while you call, make the call for you, or take the baby so you can talk without also trying to manage a tiny person.
It could be as simple as: “If you notice I’m getting stuck on how everything has to be done, tell me gently what you’re seeing. If it feels familiar to me too, I’d like you to take the baby while I call my midwife.”
If you’re doing this with a partner, switch roles. What would they want you to notice? Who would they turn to? Partners can struggle during this transition, too. Make room in the plan for what they need.
If you’re reading this and you’re already struggling, you can reach out now.
You filled out a questionnaire. What happens next?
Maybe you’ve filled out a mood questionnaire (like the EPDS) at an appointment and wondered: Did anyone read that? What would happen if I said I wasn’t doing well?
The American College of Obstetricians and Gynecologists (ACOG) recommends screening for depression and anxiety at the first prenatal visit, again later in pregnancy, and at postpartum visits. It also recommends having a system in place for timely assessment, treatment, and follow-up. Its treatment guideline recommends considering psychotherapy as a first-line treatment for mild to moderate perinatal depression.
As a patient, mental health provider, and a doula I’ve seen many providers make an effort to screen for mental health conditions throughout the care process. Unfortunately, the standard questionnaires given at most OB or pediatric offices don’t address the full range of potential symptoms and, once they’re filled out, there isn’t an adequate system for discussing the results and following up with additional resources and care.
As a brand-new mom, I wish someone had gone over that questionnaire with me. At the time, I would’ve told you I wasn’t depressed. I could also have told you I was angry all the time and couldn’t relax unless everything was done a certain way. I just didn’t know those things were worth bringing up.
If you’re staring at the form and thinking, I don’t even know where to start, I have written about what perinatal mental health symptoms can look like, including some of the signs I missed myself. If something sounds familiar, jot it down or bring the article to your appointment and point to the part that feels like you.
You can start with, “Can we look at my answers together? I’m not sure the form tells the whole story.” Then tell them what’s been happening in your day. Maybe bedtime is when you start to unravel. Maybe you’re snapping at your partner and wondering why certain things trigger you lately. You don’t have to figure out whether it’s anxiety, depression, or something else before you bring it up. That’s part of what your provider can help you sort through.
Feeling Well? How can you keep it that way?
A randomized trial in The Lancet Public Health followed 500 pregnant participants who had recurrent depression, were taking or had recently taken antidepressants, and weren’t in a depressive episode when they enrolled. Both groups could receive their usual care. One group was also offered a structured online program that combined mindfulness and cognitive therapy skills with coaching. From enrollment through six months postpartum, depression returned in 33% of the group offered the program and 44% of the group receiving usual care alone.
In this study, adding a specific therapy program to usual care made it less likely that depression would return. In my own postpartum experiences and in my work with clients, I’ve also seen how much it can matter to have support in place before you need it. There’s a difference between trying to find someone to call on a hard day and already knowing who’s in your corner.
If you’re feeling well right now, this is a good time to talk with your care team about what might help you stay well. That might mean making a plan with your prescriber, checking in with a therapist, or getting connected with individual or group peer support.
Start Your Postpartum Mental Health Plan with Nova
This is what we’re here for: helping you build support before your baby arrives and finding the right care if you’re already having a hard time.
If you’re ready to plan ahead, I created Beyond Birth: Your Guide to Thriving Postpartum, to help you start. We begin with a question I love to ask: How do you want to feel after your baby arrives? The self-paced course and worksheets help you turn your answer into a plan for who you want around, what kind of help you’d actually welcome, and how you’ll make time for rest.
Start your postpartum plan with Beyond Birth →
If you’d rather have someone alongside you
Ask about Nova’s live groups to connect with other parents
Explore individual therapy for clinical support
Connect with Adison, our peer support specialist, for one-on-one peer support and help finding resources.
You can reach out while you’re pregnant, after the baby comes, or if there is a gap in the support you have and the support you need.
