Postpartum anxiety: A holistic approach to screening and treatment

In the midst of hormonal changes, exhaustion and a redefining of one’s identity, the postpartum period can be an overwhelming time. It’s quite normal and actually beneficial to have some level of anxiety or vigilance in order to keep our newborns safe and comfortable. Yet there’s an important distinction between these emotional responses and persistent anxiety that can take over the feelings of joy, ability to rest, recover and adapt to these immense changes. 

There can also be concerning long term impacts on infant-parent bonding, infant cognitive and emotional development.² By uncovering possible risk factors and ensuring proper screening we can support new moms and parents through the fourth trimester and beyond.

Postpartum anxiety (PPA) occurs in roughly 10% of new moms, 25% of which reported feelings consistent with both depression and anxiety.¹ These numbers that have surely increased since the pandemic. PPD has more awareness, clinical screening and evidence-based management, though recent findings are suggesting PPA may have a higher prevalence and is often overlooked.^2,3

What Does Postpartum Anxiety Look and Feel Like?
PPA may present during pregnancy, immediately or within the first several months after birth. It can then last for months to years after the initial onset. Some risk factors may include a personal history of anxiety or other mental illness, previous mood alterations with hormonal changes (PMS, PMDD, birth control), history of endocrine dysfunction or nutrient deficiency (thyroid imbalance, diabetes, iron deficiency), lack of social support or lower socio-economic status.

The symptoms can be broken down as follows:⁴

• Physical: elevated heart rate, tight chest, difficulty falling or staying asleep
• Mental/emotional: racing thoughts, frequently checking the baby, ruminating or worrying about worse case scenarios
• Behavioural: preference for having full control, constantly asking for reassurance, avoidance or taking extra-precautions 

A tool known as the Perinatal Anxiety Screening Scale⁵ can be useful in practice.

A Holistic Approach
There are many available tools that we can review with our patients to help them make an informed decision. Factors involved in this decision making process can include access to care (access to virtual vs in-person consultations, ability to attend hour-long counselling or acupuncture appointments) and the severity of their symptoms (starting with a pharmaceutical vs a natural option). 

In my practice, I like to start with the basic pillars of health to rebuild a strong foundation. These can include plenty of nutrient-dense meals (with enough protein, healthy fat and whole grains), adequate hydration, a strong village of support (friends, family, healthcare team), finding rest when they can and movement in nature.

I also order blood work to rule out nutrient deficiencies (such as iron, folate, zinc, vitamin D and B12) or thyroid hormone imbalances.^6,7 In addition to dietary counselling, an effective way to prevent nutrient deficiencies is to continue taking a good quality prenatal supplement postpartum until nutrient status normalizes or until cessation of breastfeeding.

The addition of an anxiolytic depends on the severity of symptoms and options for a pharmaceutical or herbal supplement should be reviewed on an individual basis. These agents will enter the breastmilk to some degree, so reviewing observational safety data along with close monitoring of the infant is important here. Valerian root is an example of a herbal anxiolytic that can be made as a tea, tincture or bath soak.⁸ 

Acupuncture is another effective strategy to relieve perinatal and postpartum mood disorders. A systematic review and meta-analysis of its effectiveness for a number of postpartum emotional disorders is underway.⁹

Resources and Ongoing Management
Raising awareness, providing resources and implementing regular screening can help prevent and manage postpartum mood disturbances including anxiety. Parents may not report these feelings due to shame, quilt or not recognizing the severity of their symptoms. As clinicians, we have the opportunity to hold the space for new parents that may be feeling this way and to start a conversation that enables informed decision making around a treatment protocol. Resources for clinicians and patients can be found through Anxiety Canada and in the reference section below.

References

1.  (2019). Maternal Mental Health in Canada. Statistics Canada
2. Angarath I. van der Zee-van den Berg., et al (2021) Postpartum depression and anxiety: a community-based study on risk factors before, during and after pregnancy, Journal of Affective Disorders. Volume 286
3.  Zappas, M. et al. (2021). Postpartum Anxiety. The Journal for Nurse Practitioners. Volume 17, Issue 1. 60-64. 
4. (2022). Recognizing Post-Partum Anxiety. Anxiety Canada
5. Somerville, S., Dedman, K., Hagan, R., Oxnam, E., Wettinger, M., Byrne, S., Coo, S., Doherty, D., Page, A.C. (2014). The Perinatal Anxiety Screening Scale: development and preliminary validation. Archives of Women’s Mental Health. PDF Version: https://drsarahallen.com/wp-content/uploads/2015/10/PerinatalAnxietyScreeningScale2.pd
6.   Lee, D. (2021). How are Micronutrient Deficiencies Associated with Outcomes of Postpartum Anxiety and Depression in Women? Human Ecology. Vol. 5
7.   (2016). Guideline: Iron Supplementation in Postpartum Women. Geneva: World Health Organization
8.  Nice, F. et al. (2001). Herbals and Breastfeeding.
9.  Luo, N., Wang, Y., Xia, Y., Tu, M., Wu, X., Shao, X., & Fang, J. (2022). The effect of acupuncture on condition being studied emotional disorders in patients with postpartum: A protocol for systematic review and meta-analysis. Medicine, 101(4), e28669.

DR. WHITNEY BAXTER is a naturopathic doctor in Victoria, BC. Prior to becoming a naturopathic doctor, she worked as an exercise physiologist in cardiac rehab. It was here that she witnessed the value of a holistic approach to health care and understood that each individual’s physical, mental, and emotional health are interconnected. She has a general practice and enjoys working with mental wellness, digestive health and cardiovascular disease management and prevention.