After I gave birth to my son, I experienced postpartum depression.
I was also a therapist. I understood depression professionally. I knew the symptoms, the risk factors, the language we use to describe it.
It turned out that knowing something and living inside it were two very different things.
What I remember most was the distance between what motherhood was supposed to feel like and what it sometimes actually felt like.
You are supposed to be happy. Grateful. Bonded. Tired, certainly — but happily tired.
There is much less room to say:
I love my baby, but I don’t feel like myself.
I’m anxious all the time.
Sometimes my thoughts scare me.
I miss my old life.
I desperately need to sleep.
Those sentences can feel almost forbidden. And that is a problem, because some of the things mothers are most afraid to say are far more common than most of us realize.
The thoughts mothers don’t tell us about
About 1 in 7 women experience postpartum depression. Anxiety is also common. Postpartum psychosis is much rarer — roughly 1 to 3 cases per 1,000 births.
But there is another part of postpartum mental health that we talk about even less: intrusive thoughts.
In one study following 763 women through the postpartum period, 95.8 percent reported unwanted thoughts about accidental harm coming to their baby.
More than half — 53.9 percent — reported unwanted thoughts about intentionally harming their baby.
That number can sound alarming until we understand what it means.
A frightening thought is not the same thing as wanting to do something frightening.
Intrusive thoughts arrive unwanted and uninvited. A mother may be horrified by the thought precisely because it is so completely at odds with who she is and what she wants. Research has not found that mothers experiencing these unwanted intrusive thoughts are more likely to harm their babies.
That distinction matters enormously.
Because imagine that no one has ever told you this.
You have just had a baby. You are exhausted. Maybe you are anxious or depressed. Then an awful image or thought enters your mind.
You love your baby.
You know you would never hurt your baby.
But now you are afraid of your own mind.
Would you tell anyone?
Or would you worry that someone would think you were a bad mother? Dangerous? That someone might even take your baby away?
This is where our discomfort with the darker parts of motherhood can become dangerous in its own way.
If mothers become afraid to tell us what they are thinking, it becomes harder — not easier — to determine who needs reassurance, who needs treatment and who needs immediate psychiatric care.
We need to know what we are hearing
Postpartum depression, anxiety, obsessive-compulsive symptoms and postpartum psychosis are not interchangeable diagnoses.
Postpartum psychosis can involve hallucinations, delusions, severe confusion, dramatic changes in behavior and a loss of contact with reality. It is rare, can develop rapidly and is a psychiatric emergency.
A mother experiencing an intrusive thought typically recognizes the thought as frightening, unwanted and inconsistent with what she believes.
Someone experiencing psychosis may not be able to recognize that what she is experiencing is not real.
There are complexities and exceptions, and insight can vary. But clinically, the distinction matters.
Sometimes a mother needs to hear: This is frightening, but you are not the only mother who has experienced this.
Sometimes she needs treatment.
And sometimes she needs immediate psychiatric intervention.
We need women to feel safe enough to tell us what is happening so that we can know the difference.
A mother’s mental health does not exist in isolation
We also have a tendency to talk about postpartum mental health as though it exists entirely inside a woman’s brain.
It doesn’t.
A woman has gone through pregnancy and childbirth. Her hormones are changing. Her body is recovering. She may be breastfeeding, pumping, or weaning. She is suddenly responsible for a completely dependent human being, often while sleeping in fragments.
And then, in the United States, many women go back to work.
Some wean earlier than they wanted to.
Some pump between meetings.
Some are awake multiple times during the night and are expected to show up the next morning and think clearly, manage people, make decisions and behave as though they slept.
Then we are surprised when women struggle.
Research has associated inadequate maternity leave and disrupted sleep with poorer postpartum mental health, particularly postpartum depression. That does not mean either one, by itself, causes postpartum depression. Mental illness is more complicated than that.
But context matters.
Sleep is not a luxury.
Neither is time to recover.
And support cannot simply mean having another person in the house. A woman can be surrounded by people and still not be getting what she actually needs.
Which brings me to Lindsay Clancy
Jessica Grose recently wrote about the case of Lindsay Clancy, the Massachusetts mother accused of killing her three young children.
It is difficult to write about this case without losing sight of one of two realities: three children died, and their deaths are horrifying; and there are serious questions about what was happening psychiatrically to their mother.
Both realities have to be held at once.
According to testimony described by Grose, Clancy repeatedly sought psychiatric help. She wrote about “horrible thoughts” in her journal. She experienced severe insomnia. Over a period of four months, she was prescribed 13 different psychiatric medications as clinicians attempted to treat her worsening symptoms.
After seven days of deliberation, the jury could not reach a unanimous verdict, and the judge declared a mistrial.
I don’t know what was happening inside Lindsay Clancy’s mind when her children died. None of us outside that courtroom does.
And I think that uncertainty matters.
Her case should not become evidence that women with postpartum depression, anxiety or intrusive thoughts are dangerous. That would be both clinically misleading and potentially harmful.
But the case raises another question that is harder to dismiss:
How good are we at hearing women when they tell us that something is terribly wrong?
Grose makes an important point here. Clancy had resources that we often identify as protective: insurance, maternity leave and family support.
And still, something went catastrophically wrong.
Having access to care is not necessarily the same thing as receiving the right care.
Having multiple clinicians is not necessarily the same thing as having someone recognize the whole picture.
And being prescribed medication is not necessarily evidence that the underlying condition has been correctly understood.
Postpartum psychosis is rare. It can also emerge quickly and can be difficult to recognize.
That makes listening carefully even more important.
Maybe we need to ask better questions
We ask new mothers whether the baby is eating.
We ask whether the baby is sleeping.
We ask about breastfeeding.
We ask whether they are enjoying motherhood.
Maybe we also need to ask:
What has motherhood felt like inside your head?
And then make it possible for a woman to answer truthfully.
Because a woman can love her baby deeply and still miss her old life.
She can be grateful and depressed.
She can desperately want to breastfeed and desperately want to stop.
She can adore her child and resent being needed every minute of every day.
She can want someone else to take the baby for a few hours and still be a loving mother.
And she can have a frightening thought without being a frightening person.
That last distinction may be one of the most important.
We should not normalize symptoms that suggest psychosis or imminent danger. Hallucinations, delusions, severe confusion, rapidly changing behavior, prolonged inability to sleep, or thoughts accompanied by an urge or intention to harm yourself or your baby require immediate professional evaluation.
But we should normalize talking about what is actually happening.
Because silence doesn’t protect mothers or babies.
Good assessment does.
I know some of this because I’m a therapist.
I know some of it because I’ve lived it.
And what I remember from my own postpartum depression is not simply being depressed. I remember how strange it was to feel something so different from what I thought I was supposed to feel.
That gap — between the cultural story of motherhood and the lived experience of it — is where shame can grow.
We can make that gap smaller.
Not by making motherhood sound darker than it is.
Not by frightening women about rare psychiatric illnesses.
And certainly not by treating every unwanted thought as evidence of danger.
We make it smaller by giving mothers more language, more sleep, better assessment, better psychiatric care and more permission to tell the truth.
Especially when the truth is uncomfortable.
The goal isn’t to make motherhood darker.
It is to make it safer for a mother to tell us when, for her, it is.
-Denica Gordon-Mandel, M.A., MSW, LCSW, & Director, Women’s Wellness Program at CBH Partners
Sources & Further Reading
* Fairbrother et al. — Intrusive thoughts of infant-related harm: Prospective research involving 763 women examining the prevalence and characteristics of unwanted thoughts about infant-related harm. PubMed.
* Fairbrother et al. — Intrusive thoughts, OCD and infant safety: Research examining whether unwanted intentional-harm thoughts or postpartum OCD are associated with maternal aggression toward infants. PubMed.
* Hidalgo-Padilla et al. — Maternity leave and postpartum depression: Systematic review examining maternity-leave policies and postpartum depression. PubMed.
* Sleep and postpartum mental health: Systematic review examining sleep disturbance and postpartum mental disorders, with particularly strong evidence involving postpartum depression. PubMed.
* National Maternal Mental Health Hotline: Information and support for pregnant and postpartum people and their families from the U.S. Health Resources & Services Administration.
A Note About Mental Health
This article is intended for education and discussion and is not a substitute for individualized mental-health or medical care.
If you are pregnant or postpartum and struggling, you do not have to wait until you are in crisis to ask for help. The National Maternal Mental Health Hotline provides free, confidential support 24 hours a day, 7 days a week. Call or text 1-833-TLC-MAMA (1-833-852-6262).
If you are experiencing a mental-health crisis or are concerned that you may harm yourself or someone else, call or text 988 to reach the Suicide & Crisis Lifeline. If there is immediate danger, call 911 or go to the nearest emergency department.