Perinatal anxiety refers to anxiety disorders during pregnancy or in the year after childbirth. It affects roughly 15 to 20 percent of pregnant and postpartum people. The estimate is supported by systematic reviews and is reflected in guidance from the American College of Obstetricians and Gynecologists and by Postpartum Support International. It often goes unrecognized and is highly treatable. The treatment picture differs from anxiety in other adults primarily in the medication considerations, which require careful weighing of risks of treatment versus risks of untreated illness.
Perinatal anxiety is the most common psychiatric condition in pregnancy and the postpartum period, more common than postpartum depression, and frequently missed because attention focuses on mood rather than anxiety. The clinical reality is that the two often coexist, and treating one without addressing the other tends to be inadequate. Perinatal anxiety often coexists with perinatal depression; our companion publication DepressionResource.org covers postpartum depression and the broader picture of perinatal mood and anxiety disorders.
What perinatal anxiety actually is
The term "perinatal" covers pregnancy and the first twelve months after birth. Anxiety in this period can present as any of the standard anxiety disorders, generalized anxiety, panic disorder, OCD, PTSD, social anxiety, or as anxiety symptoms not meeting full diagnostic criteria but still causing significant impairment.
Specific presentations clinicians see often.
Postpartum OCD. Intrusive thoughts about harming the infant are common and almost always egodystonic, the parent finds them horrifying. The thoughts aren't predictive of action. Postpartum OCD responds well to ERP and SSRIs and is meaningfully different from postpartum psychosis, which involves loss of insight and is a psychiatric emergency.
Postpartum panic disorder. Often emerges or worsens in the first three months after birth, sometimes triggered by sleep deprivation and hormonal changes.
Generalized worry about infant safety. Some level of worry is normal. When the worry becomes constant, interferes with sleep beyond what the infant requires, drives constant checking behaviors, or prevents normal functioning, it crosses into clinically significant anxiety.
Birth-related PTSD. A traumatic birth experience can produce PTSD symptoms in the postpartum period that are treatable with the same evidence-based therapies used for PTSD generally.
Why it's often missed
Several factors. Postpartum visits focus on the infant, not the parent. Screening for postpartum depression has become standard, but screening for anxiety hasn't in many practices. Parents are reluctant to disclose intrusive thoughts about harming the infant out of fear of judgment or child protective services involvement. Sleep deprivation and physical recovery from birth produce symptoms that overlap with anxiety and can be dismissed as normal.
Treatment considerations
The core treatments, CBT, SSRIs, exposure work, are the same as for anxiety in non-perinatal patients. The decision-making around medication is what differs.
During pregnancy. SSRIs have the most data of any psychiatric medication class in pregnancy. sertraline has the most reassuring data and is often preferred when an SSRI is started during pregnancy. paroxetine is generally avoided in the first trimester because of slightly elevated cardiac malformation risk in some studies. The decision is made with both a psychiatrist and the obstetrician.
The risks of untreated anxiety in pregnancy are real and include preterm birth, low birth weight, and effects on infant attachment and development. The decision isn't "treatment versus no treatment." It's "which treatment, weighing risks against the risks of the underlying illness."
During breastfeeding. Most SSRIs are considered compatible with breastfeeding, with sertraline being the most-studied. The LactMed database is the standard reference for medication safety during lactation.
Therapy. CBT and interpersonal therapy have strong evidence in perinatal anxiety and depression and are first-line for many patients, with or without medication.
The importance of postpartum screening
The American College of Obstetricians and Gynecologists recommends screening for perinatal mood and anxiety disorders at least once during the perinatal period. Many practices use the Edinburgh Postnatal Depression Scale, which includes anxiety items, or the GAD-7 alongside the PHQ-9. Patients should expect to be asked about both mood and anxiety; if they aren't, raising it directly is reasonable.
External references
The NIMH page on perinatal depression covers the broader perinatal mood and anxiety landscape, including anxiety presentations. The LactMed database covers medication safety during breastfeeding.
For more on the postpartum side specifically, see postpartum anxiety, the overlooked side of new parent mental health on shrinkMD. (shrinkMD is part of The Shrink Network, founded by Shariq Refai, MD, MBA.)
Related: Generalized anxiety disorder · Obsessive-compulsive disorder · How CBT and SSRIs actually work for anxiety
For the clinical encyclopedia entry on this condition, see Shrinkopedia →