Postpartum Mental Health: Beyond the Baby Blues
Written by Melissa Schenkman, MPH, MSJ
Alex McNulty is a clinical social worker and owner of McNulty Wellness Collective who specializes in anxiety disorders, OCD, and perinatal mental health. She combines evidence-based therapy with a holistic approach, supporting women through pregnancy, postpartum, and beyond.
What inspired you to specialize in perinatal and postpartum mental health?
Alex: “A lot of my specialization grew organically from my other areas of focus—anxiety, OCD, and perfectionism. I started to notice how much these issues overlapped with what women experience during the perinatal period. To be transparent, a lot of this also grew out of my own personal experience of becoming a mom two years ago.
I decided to offer therapy specifically in this area because it's a time where women really need a lot of support. There's no lack of information out there—anyone on the internet can tell you that—but this information often becomes overwhelming and tends to make moms feel worse. Unfortunately, a lot of advice that people get may be well-intentioned but isn't often well-received or helpful. I felt passionate about helping other moms navigate this time without inadvertently contributing to the difficult feelings they might be experiencing.”
Why is there such a disconnect between society's expectations of pregnancy/motherhood and the reality?
Alex: Our society tends to romanticize pregnancy and motherhood, yet at the same time doesn't actually provide any structural support to make it feasible or make it the wonderful time that everyone hopes it could be. We're talking about things like paid parental leave, affordable childcare—the list goes on and on.
At the end of the day, there's an enormous gap between expectation and the support that is given, and moms are unfortunately expected to fill in that gap themselves.
What mental health conditions can occur during the postpartum period beyond depression?
Alex: It's interesting because in society we say "postpartum" and the implication is often postpartum depression. But there are many other conditions to be aware of:
Postpartum anxiety - which I actually see quite commonly
Postpartum OCD - wildly under-discussed but very important
Postpartum PTSD - following a traumatic birth, loss, or significant event
Perinatal psychosis - less frequent but critical to recognize
Bipolar disorder - about 50% of women who receive a bipolar diagnosis actually receive it during the postpartum phase, which surprises many people
Beyond diagnoses, I commonly see issues like postpartum rage, loss of identity, and challenges with body image. We use the term "matrescence" to describe the significant transition that moms undergo during this time—it's comparable to adolescence, but women often aren't given the space or attention that this transition deserves.
Who is at higher risk for developing postpartum mental health conditions?
Alex: Jokingly, I think the most obvious risk factor is living in the United States! But in all seriousness, we're all at risk being in a developed country that has pretty abysmal support for new parents.
Other risk factors include:
Pre-existing mental health conditions
Operating as a single parent or doing this alone
Financial stress
Having a baby in the NICU
A traumatizing or disappointing birth experience
Being in a marginalized community, including the queer and trans community, women of color
It's extremely multi-causal. It would be nice if there was one risk factor we could pay attention to, but it's a combination of many environmental and structural factors.
How can someone distinguish between "baby blues" and postpartum depression?
Alex: It's helpful to focus on two factors: duration and functioning.
Baby blues tend to last about two weeks, give or take, and typically occur with that big hormonal shift right after giving birth. With baby blues, you can expect tearfulness, mood swings, trouble focusing and concentrating, yet still be able to function.
Postpartum depression lasts much longer, especially if left untreated, and can occur within the first year postpartum. With depression, there's more impairment in functioning, along with withdrawing socially or from activities, lack of interest, a "why bother" attitude, loss of appetite, worthlessness, guilt, and hopelessness. Of course, thoughts of harming yourself or the baby would be absolute reasons to seek help immediately.
Alex McNulty is a therapist and the founder of McNulty Wellness Collective. Her experience ranges from working with persistent, severe mental illness in a private, inpatient psychiatric facility to individual outpatient therapy at Johns Hopkins Bayview, as well as specializing in anxiety disorders. At her Collective, she offers a variety of services, including therapy during pregnancy, the postpartum period, and beyond.
McNulty earned her Master of Clinical Social Work from the University of Pennsylvania in 2015. She is also Board Certified in Holistic Nutrition
What about postpartum anxiety—how do we know when it's beyond "normal" new parent worry?
Alex: Our culture normalizes a lot of worry and even equates worry with being a good mom, which I have a lot of thoughts and feelings about. There's this expectation that new moms are supposed to be worried because "that just means you care." But sometimes it's at a point where it's incredibly debilitating.
Pay attention to:
Needing constant reassurance
Getting pulled into "what ifs" despite evidence showing there's no issue
Starting to doubt what your senses are telling you
Physical symptoms like heart racing, dizziness, trouble eating or sleeping
Avoidance behaviors—avoiding leaving the house, driving, letting someone else help with the baby, or even avoiding holding the baby yourself
I also want to highlight perinatal OCD, which is wildly under-discussed. If someone is experiencing really intrusive thoughts about the baby being in danger or other upsetting intrusive thoughts, this needs attention. I experienced this myself—3 a.m. thoughts of "don't bother getting attached to him, he's going to die." Even as a therapist who knows what intrusive thoughts are, that didn't stop it from being excruciatingly horrifying to experience.
When should someone seek professional help?
Alex: I'm biased, but I would say anytime! Sometimes there's a "mother martyr syndrome" of "if I'm suffering, that's just part of it." But nobody has to go through this alone. You don't have to wait until it's "bad enough"—there's not this magical threshold where until you reach it, you'll be fine.
Anyone would benefit from support during this extremely significant time. I encourage folks to start when they become pregnant to have ongoing support during the entire transition. We should normalize this.
If emotions or symptoms become more pervasive, less situational, and more unchanging, that's definitely a good indicator to talk to somebody.
What are the most common issues you see in your practice?
Alex: The issues I see most frequently are the "shoulds" and the guilt that comes up during motherhood. Moms constantly feel like they're doing the wrong thing, and it makes sense because, according to somebody on the internet, you are!
A lot of the work becomes helping moms build trust in themselves. I believe that new parents possess an innate wisdom, but it gets drowned out by all that external noise. We want to minimize that noise.
I don't tend to give advice in my practice—that's not my role as a therapist—but there is always one piece of advice I give new moms during that initial phase: stay off social media.
How do you address the challenges of being a working mother?
Alex: I work with a lot of women who would identify as very high-functioning professional women. I hate the phrase "work-life balance" because it implies this seesaw where if you're focused at home, then you're not focused at work and vice versa. It makes women feel like they can never be enough anywhere.
I prefer to use the term "work-life integration"—it's more realistic for integrating this new identity with your old identity. For professional moms, there's guilt not just from the childcare aspect, but also about where your focus lies and the things you care about.
I remember when I first had my son, I was excited to return to work, but I felt like I couldn't talk about that. I felt guilty that I was looking forward to returning to those other aspects of myself, as if it meant I wasn't paying enough attention to my son. It's about integration rather than balance.
What therapeutic approaches do you use?
Alex: I love Acceptance and Commitment Therapy (ACT), especially for the perinatal period, because it allows us to relate to our thoughts and emotions differently. There are going to be challenging and painful thoughts and emotions during this time.
Rather than focusing on challenging and changing thoughts (like traditional Cognitive Behavioral Therapy (CBT) ), I prefer to help clients relate to their internal experiences differently so they hold less power. We want to control our actions by returning to our value system and how we're showing up.
I also focus heavily on foundations: nourishment through food, sleep (even suggesting partners take shifts—it's okay to do that!), water, sunlight, movement, and socialization. If we don't take care of the body and whole person, trying to focus on cognitive strategies is like picking out countertops without the basement being built.
What's a typical timeline for seeing improvement?
Alex: It truly depends on a person's goals and what they're presenting with, and it's not uncommon for those goals to change. If we're working on an acute issue and stabilization, that could take a few weeks. For emotional regulation and identity shifts, those might change over a few months.
If there's anything true during the newborn and baby phase, it's that things change very rapidly. We focus on quality of life and wellbeing improvement, but there are many changes that take place, especially during that first year.
What has surprised you most in your work with postpartum clients?
Alex: I'm always taken aback by how therapeutic it can be to simply say to somebody, "Yeah, that makes sense. I get that." Sometimes the most powerful intervention is validation—being like, "Yeah, it makes sense to feel that way." You can see the exhale take place.
These are often invisible struggles that people are experiencing. While therapists have specific clinical interventions, there's so much power in just being there and providing that space to focus on yourself, breathe, and let it all out without judgment.
What do you want people to understand most about postpartum mental health conditions?
Alex: If someone's struggling, it doesn't mean anything about them as a mom or how much they care about their kid. That's a common fear I see across the board. These issues exist separately from somebody's care and love.
A lot of the time, someone might feel so depressed or anxious that they struggle to bond with their baby—which, for everybody, doesn't happen the way they depict in movies. It's a relationship; it takes time to build. But these issues are often exaggerated because new moms care so much and they're so debilitated by the lack of support, societal expectations, and changes they're experiencing.
We need to give women the space to figure it out and feel what they feel without that sense of "well, at least this" or "shouldn't you be grateful?"
How can friends and family best support someone experiencing postpartum mental health challenges?
Alex: Validate, listen, and say it makes sense. Don't be quick to problem-solve—you're not responsible for being their therapist. You're just there to listen. Avoid starting sentences with "at least" or trying to minimize their experience. Give people space to express how they feel, knowing that emotions are complex and multiple emotions can exist at once.
As far as practical support, minimize decisions that need to be made. Some of the most helpful things people did for me were just: "Hey, I dropped off food, it's outside. There's no expectation, no decision on your end."
Sometimes it's really just sitting in the difficult moments with somebody.
CTA: Want to hear more from Alex? Listen to her episode on the YMyHealth podcast!