Authors: Lauren Wallace, Meghan Etsey, Jessica Pineda, MD on behalf of the Gender Equity Task Force

Pregnancy and the postpartum period are often framed as routine physiologic milestones, with clinical care focused on fetal development, delivery outcomes, and maternal vital signs, while the substantial psychiatric vulnerability of this period remains underemphasized. Yet depression, anxiety, and other perinatal mood and anxiety disorders are among the most common complications of pregnancy and postpartum, affecting approximately one in five women (ACOG, 2023; Fawcett et al., 2021). Maternal mental health is still too frequently treated as an individual struggle rather than a patient safety and public health issue, leading to widespread underrecognition and undertreatment, as symptoms are dismissed as normal hormonal changes, sleep deprivation, or expected stress even when significant impairment is present (Fairbrother et al., 2022; Wenzel et al., 2021). Consequently, many women move through prenatal and postpartum care without adequate screening, follow-up, or access to treatment, particularly beyond the traditional six-week postpartum visit (ACOG, 2023; USPSTF, 2023), despite national data showing that mental health conditions, including suicide and overdose, are a leading cause of pregnancy-related mortality in the United States, especially in the year following delivery (CDC, 2022; Tikkanen et al., 2020–2023). 

Perinatal mental health disorders are far more common than is often recognized in routine obstetric care, with depression affecting an estimated 15 to 20 percent of women during pregnancy and the postpartum period and anxiety disorders impacting as many as 20 to 25 percent, frequently occurring with depressive symptoms (Fawcett et al., 2021; ACOG, 2023). Although postpartum psychosis is rare, occurring in approximately 1 to 2 per 1,000 births, it constitutes a psychiatric emergency with a high risk of harm to both mother and infant if not rapidly identified and treated (ACOG, 2023). The consequences of untreated perinatal mental illness are increasingly evident at a population level, as mental health conditions including suicide and substance related deaths are now recognized as a leading contributor to pregnancy related mortality in the United States, with the highest risk occurring in the postpartum period rather than during pregnancy itself (CDC, 2022; Tikkanen et al., 2020 to 2023). These data challenge the traditional focus on obstetric complications alone and underscore the need for sustained mental health surveillance beyond delivery, particularly given persistent disparities in diagnosis and treatment, as Black, Indigenous, rural, and low income women bear a disproportionate burden of perinatal mental health disorders while remaining less likely to be screened, accurately diagnosed, or receive timely treatment due to structural barriers such as limited access to care, insurance gaps, and systemic bias within healthcare systems (CDC, 2022; ACOG, 2023).

Pregnancy and the postpartum period confer several unique, overlapping risk factors for psychiatric illness. Biologically, rapid fluctuations in estrogen, progesterone, and cortisol, alongside sleep deprivation and circadian rhythm disruption, increase susceptibility to mood and anxiety disorders (Biaggi et al., 2021; Meltzer-Brody et al., 2023). A family history of perinatal mood and anxiety disorders further increases risk, reflecting genetic and shared vulnerability to hormonally mediated affective dysregulation (Bauer et al., 2019). Psychologically, a prior psychiatric history is the strongest predictor of perinatal mental illness, with additional risk associated with trauma exposure, infertility, and prior pregnancy loss (Howard & Khalifeh, 2020; Biaggi et al., 2021). Social and structural factors further compound risk, including lack of paid parental leave, limited childcare support, intimate partner violence, and the effects of racism and systemic bias in obstetric care, all of which contribute to delayed diagnosis and poorer maternal mental health outcomes (Howard & Khalifeh, 2020; Meltzer-Brody et al., 2023). 

Several perinatal psychiatric conditions are frequently overlooked or misattributed to normal postpartum adjustment. “Baby blues” may obscure major depressive disorder, while perinatal anxiety often presents with somatic symptoms such as palpitations, dyspnea, or gastrointestinal distress rather than overt worry (Fairbrother et al., 2022). Obsessive-compulsive symptoms, particularly intrusive thoughts, are commonly minimized as “normal new-mom worries,” despite causing significant distress and functional impairment (Wenzel et al., 2021). More critically, postpartum psychosis may be mistaken for sleep deprivation or an adjustment disorder, delaying urgent intervention. Key clinical red flags include intrusive thoughts of harm to the infant that are ego-syntonic (experienced as consistent with the patient’s thoughts rather than distressing), severe insomnia despite adequate infant sleep, rapid mood shifts, and paranoia or disorganized thinking. Thoughts of suicide, which may or may not include a plan or clear intent, also warrant prompt psychiatric evaluation due to the elevated risks of infanticide and suicide associated with postpartum psychosis (Fairbrother et al., 2022; Wenzel et al., 2021).

Validated tools such as the Edinburgh Postnatal Depression Scale (EPDS), PHQ-9, and GAD-7 are recommended for identifying perinatal mood and anxiety disorders; however, real-world implementation remains inconsistent (ACOG, 2023; O’Connor et al., 2023). The Mood Disorder Questionnaire (MDQ) is also recommended, as current ACOG guidance advises screening for bipolar disorder prior to initiating pharmacotherapy for anxiety or depression. Common gaps include variable screening across prenatal and postpartum visits, screening without clear referral pathways, and missed cases after the traditional 6-week postpartum visit, when risk often persists or emerges later (USPSTF, 2023). Screening is most effective when repeated across pregnancy and multiple postpartum time points and integrated into primary care and pediatric settings, where patients frequently present (ACOG, 2023). Given the high prevalence of birth-related trauma and other interpersonal violence among women of reproductive age, PTSD screening should also be considered, even among patients with uncomplicated deliveries, using brief tools when time-limited (e.g., short-form PTSD checklists), particularly for those with complicated deliveries or NICU admissions (O’Connor et al., 2023; Resnick et al., 1993). Untreated perinatal mental illness carries significant consequences for mothers, infants, and families. 

Maternal outcomes include increased risk of suicide and overdose, now leading causes of pregnancy-associated death, as well as impaired functioning and disrupted maternal–infant bonding (Grigoriadis et al., 2021). Infant and child outcomes are also affected, with higher rates of preterm birth and low birth weight, along with long-term risks to emotional regulation and cognitive development (Stein et al., 2022). At the family systems level, untreated illness contributes to increased partner stress, relationship strain, and broader family instability, reinforcing intergenerational cycles of risk (Grigoriadis et al., 2021; Stein et al., 2022).

Improving perinatal mental health outcomes requires coordinated, systems-level change. Evidence supports universal perinatal mental health screening mandates, integrated obstetric–psychiatric care models, and extended postpartum insurance coverage to at least 12 months, particularly through Medicaid expansion (Mangla et al., 2021; CMS, 2022–2024). Structural supports such as paid parental leave and workplace protections reduce stress and improve recovery during the postpartum period. In parallel, training OB/GYNs, midwives, and primary care clinicians in perinatal psychiatry fundamentals is critical to closing care gaps and reducing delays in treatment initiation (ACOG & APA, 2023). 

Mental health care must be recognized as essential obstetric care, not an optional add-on. Screening alone is insufficient without timely access to evidence-based treatment and referral pathways. Addressing maternal mental health improves outcomes not only for mothers, but for infants, families, and future generations. A healthy pregnancy includes a healthy mind.

References

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About the Authors

Meghan Etsey, MS4

Meghan Etsey is a fourth year medical student from St. George’s University. She has a Bachelors of Arts in Biology and a Bachelors of Arts in Nutrition and Dietetics from Bluffton University in Bluffton, Ohio. She served as the President of the St. George’s University’s Women in Medicine chapter in St. George, Grenada where she expanded relationships with the community and worked towards educating women and helping the youth. She is also a member of the Gender Equity Task Force and Sex and Gender Health Collaborative Committees within the American Medical Women’s Association. When she is not pursuing medicine, you can find her with her friends and family on different road trips and adventures exploring the world. 

Lauren Wallace, MS3

Lauren Wallace is a third-year medical student at St. George’s University School of Medicine and earned her Bachelor’s degree in Cell and Molecular Biology from the University of Tennessee at Martin. She has served as student lead for her Psychiatry and Obstetrics/Gynecology core rotations and is a member of the Gender Equity Task Force. Growing up in rural Tennessee, she is passionate about improving healthcare access for underserved communities. Outside of medicine, she enjoys staying active and scuba diving with her husband.

Jessica Pineda, MD


Jessica Pineda, MD is a reproductive psychiatrist at Women & Infants Hospital, an Assistant Professor in the departments of Psychiatry & Human Behavior and Family Medicine at The Warren Alpert Medical School of Brown University and the Program Director for the Women’s Mental Health Fellowship at Brown University. Her clinical work focuses on the mental health of women across the reproductive life cycle. She provides outpatient medication management and inpatient consult-liaison services for women experiencing mental health disorders during the perinatal period, as well as for those with mood disorders throughout different stages of life. Her areas of expertise include perinatal mental health, Premenstrual Dysphoric Disorder (PMDD), perimenopause-related mood changes, and psycho-oncology. Dr. Pineda is also involved in advancing integrated care models, working to embed psychiatric services within primary care and obstetrical settings. She serves as the consulting psychiatrist for COMPASS+, a grant-funded collaborative care initiative that delivers perinatal behavioral health services to OB-GYN clinics across Rhode Island.