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Understanding and treating PMADs (perinatal mood and anxiety disorders)

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For many decades there has been an awareness of mood disorders grouped under the title of PMADs, which describe changes that mothers undergo during and immediately after childbirth. Now, the new experiences brought on by the pandemic have thrown an extra light on the subject. Now we have been given some guidelines on how the outcomes can be better managed and how the disorders can be prevented in the first place.

Prior to the onset of the COVID-19 pandemic, according to the World Health Organization, the estimated incidence rates of women experiencing significant symptoms of depression and/or anxiety during the postpartum period (within a year of delivery) was between 10% and 15%. The first year of the pandemic saw that rate skyrocket, almost tripling to one-third of all new births. 

Understanding PMADs

The broad group of perinatal mood and anxiety disorders (PMADs) includes pregnancy and postpartum depression, postpartum anxiety, and baby blues.

They include a variety of moderate to severe mood and anxiety symptoms that usually require professional health treatment. The symptoms presented often include many of the following:

  • depressed mood
  • severe anxiety attacks
  • panic attacks
  • insomnia and/or sleep disturbances
  • appetite loss
  • feelings of hopelessness or worthlessness
  • suicidal thoughts
  • loss of pleasure or joy – especially in sex
  • lack of energy and motivation
  • difficulty in functioning at the mental or physical usual levels
  • inability to cope with life’s everyday demands
  • rumination
  • obsessive and disturbing thoughts.

In far less common cases, these can even be symptoms of mania and psychosis.

Distinguishing between the different forms of PMAD

Is it baby blues, postpartum anxiety, or postpartum depression?

The baby blues are a very common reaction in the first few weeks after you come home with your newborn child. They are largely attributable to the sudden decrease in hormone levels after delivery. They can leave you feeling overwhelmed, sad and weepy. Usually, these are mild reactions and only last for a few weeks. However, if they persist or become debilitating, then there could be something else going on. The distinguishing differences between baby blues and postpartum depression are the severity and length of time.

More severe than baby blues comes postpartum anxiety which may start due to spikes in hormone levels during the postpartum period. It may also develop in response to real stressors, such as the baby’s health, changes in the home environment, sleeping patterns or domestic relationships. A history of stillbirth or miscarriage also increases the risk of developing postpartum anxiety. The same goes if symptoms of generalized anxiety disorder were present before or during pregnancy. Hormonal changes after weaning from breastfeeding may also trigger anxiety.

In the severest form, which is postpartum depression, mothers can experience panic attacks or symptoms of obsessive-compulsive disorder (OCD). Panic attacks are distinct episodes characterized by physical symptoms like rapid heartbeat, shortness of breath, and dizziness of intense anxiety, accompanied by intrusive and unwanted thoughts. They can be accompanied by compulsive or deliberate actions to relieve distress which can be frightening to a new mother, particularly if these thoughts involve harming the baby. 

What are the treatments for baby blues, postpartum anxiety and postpartum depression?

It’s essential to consult with a physician if the feelings of baby blues don’t clear up within a few weeks or even sooner if they are getting more severe. Doctors can prescribe general anxiety and mood medications that can be helpful. They are often suggested along with therapy such as CBT (cognitive behavioral therapy). 

The first line of treatments for anxiety disorders are the classes of drugs known as selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs). 

Selective serotonin reuptake inhibitors (SSRIs.)

For the treatment of postpartum depression or anxiety, three drugs that are most often prescribed are vortioxetine (Trintellix), fluoxetine (Prozac) and escitalopram (Lexapro). Selective serotonin reuptake inhibitors are taken to improve mood, sleep patterns, appetite, and energy levels in patients diagnosed with this disorder.

The choice is made mainly by a prescribing physician based on interactions with other drugs the patient may be taking, possible allergies to by-products in each drug, and several other factors. In some cases, it is a matter of trials to determine which of the three drugs works best for a specific patient. 

The FDA has approved Prozac to treat obsessive-compulsive disorder (OCD) and panic disorder in patients experiencing the more severe forms of PMAD.

SSRI drugs generally have mild side effects, like dry mouth, nausea and diarrhea, headaches, insomnia, sleepiness or fatigue. The side effects usually diminish as usage of the drug continues. 

Serotonin and norepinephrine reuptake inhibitors (SNRI)

Serotonin and norepinephrine reuptake inhibitors (SNRIs) are prescribed to treat depression, anxiety disorders, and chronic nerve pain. SNRIs may be prescribed for patients with both chronic pain and depression. The SNRI drug most often prescribed for treating PMADs is venlafaxine (Effexor XR). 

The main difference between SSRIs and SNRIs is that SNRIs are not selective only for serotonin. They prevent the reuptake of both serotonin and norepinephrine. Norepinephrine is a neurotransmitter similar to serotonin, used to send messages between nerve cells. 

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