Primary carers are likely to be at increased risk of mental health problems when trapped at home.
“I hardly got through the last lockdown with my baby. I just can’t face it again.”
Mothers and babies are particularly vulnerable during covid-19 lockdowns.
New, high-level evidence confirms that in the current pandemic, women in the perinatal period are even more likely to develop symptoms of anxiety and depression than were perinatal women prior.1-3
The volume of calls coming through to Perinatal Anxiety and Depression Australia (PANDA) and Gidget Foundation Australia – both of which offer free specialist perinatal telehealth counselling services – has doubled since SARS-CoV-2 so dramatically disrupted our lives.4
Although I mostly refer to mothers and babies in this article, I’m keen to acknowledge that primary carers may be fathers, parents of non-binary gender, grandparents and others. All primary carers are likely to be at increased risk of mental health problems during lockdown. Just a reminder too that the baby’s other parent is at increased risk of mental health problems in the perinatal period.5
Your practice might already be screening for postnatal anxiety and depression by inviting women with babies to fill out the iCOPE digital screening tool before appointments. As GPs, our role in the care of mothers and babies during lockdown is multi-faceted, but includes:
- Early identification of a woman who is at risk of mental health problems, in order to set up regular – maybe even weekly – check-ins for a time (e.g., by telehealth) and to link her into online peer and other support (see Box 1).
- Early identification of a diagnosable mental health problem – for example, postnatal anxiety and depression – in order to provide psychological and, if necessary, pharmaceutical interventions (see Box 2).
|Some key risk factors for postnatal depression|
|History of anxiety and/or depression or mental health problems|
Antenatal depressionBreastfeeding, cry-fuss or sleep problems
Limited family support
History of gender-based violence
|Pharmaceutical treatment for postnatal depression|
|A 2021 Cochrane Review investigating antidepressant treatment for postnatal depression concludes: “The evidence base to guide clinicians on the effectiveness of antidepressants in their management of women with postnatal depression remains unclear, particularly for women with severe postnatal depression” (p 34).6 That is, few studies of pharmacological interventions include women with severe depression and suicidality. Though unable to distinguish between degrees of illness severity, this Cochrane analysis finds that women treated with antidepressants respond slightly better than those given a placebo pill.6 In more severe postnatal depression, antidepressants are likely to have a place, in conjunction with psychological interventions, after careful collaborative discussions about risk versus benefit.7-10|
Parents and referring health professionals are finding it difficult to access timely individual psychological and psychiatric support at the moment because of the pressure the pandemic has placed on mental health services. In this Hey baby! article, I focus on strategies that may help prevent the emergence of perinatal and infant mental health problems during lockdown, or which may be useful as early intervention (see Box 3.)
As health professionals, we need to be aware that messages that instill fear and anxiety (e.g., about the risk posed by lockdown to a mother’s mental health or baby’s development) can undermine maternal well-being. Our job is to identify the vulnerable minority, but we know most women and babies will get through OK. Emphasising this helps families maintain perspective. You might offer the following words to support a new mother’s resilience.
Work out what really matters. Caring for a baby during lockdown is extraordinarily challenging. Your little one will very likely be telling the story of how she was born into the covid pandemic all her life! What sort of parent do you want her to be able to say you were through the pandemic? Do you want to be responsive to your baby’s communications and cries, even when the going is tough? What is your responsibility to yourself, for self-care? If you are locked down with your partner, spend time discussing what really matters to you both in this crisis? How will you protect your relationship through such a stressful time?3
Once you’ve clarified what matters to you, what kind of person and mother you want to be, then even when you are buffeted by boredom, by loneliness, or by other powerful and painful feelings; even when your mind is full of very unhelpful thoughts (such as the common unhelpful thought ‘I’m failing as a mother’), you will know how you want to behave. We often can’t stop ruminations or miserable thoughts, and trying to get rid of them can sometimes even make them worse. We often can’t stop anxious feelings or an exhausted numbness from lodging in our chest or in our belly. But a newer form of Cognitive Behavioural Therapy known as Acceptance and Commitment Therapy (ACT) offers particularly powerful strategies for protecting your mental health, by changing your relationship with these difficult thoughts and feelings, rather than by trying to get rid of them.11-13 (And although getting rid of painful thoughts and feelings isn’t the aim, we tend to feel better over time once anxious or painful thoughts and feelings no longer control our behaviour. A full and meaningful life is created, minute by minute, through the behaviours we choose, even in the context of the severe constraints of lockdown.) To find out more about how to use ACT in the perinatal period, you could watch some short videos available here.
Your baby might cry and fuss more than he would have otherwise, due to constrained sensory experiences, but this is the nature of the times we are living in. Extraordinary times demand, it seems to me, a minute-by-minute practice of self-compassion, and a courageous commitment to workability in your relationship with your baby, rather than perfection.
Expect to be visited by sadness and grief. We don’t usually imagine we will bring our babies into a world of pandemic-induced lockdowns. You may already be feeling the grief (or even the anger) of having given birth without a loved one by your side, of things not having gone as you’d planned. Now you face tedious days locked down in the company of a baby, thanks to covid-19, quite a different experience to the one you’d dreamed of and hoped for.
Dr Russ Harris calls this gap between what we’d imagined and what we actually experience a “reality gap”. Reality gaps are typically accompanied by feelings of grief and loss. Having strategies in place for managing painful feelings becomes very important. We might practise feeling the grief or other unpleasant sensation such as anxiety in our body, making room for it, breathing around it, understanding we can’t necessarily get rid of it in the same way we can’t get rid of the weather. But we can also expand our attention and notice other things in the world around us at the same time (as constrained as our world might be right now), noticing what we can see and hear and touch and smell, anchoring ourselves in this present moment.
Get very good at planning. For most primary carers, structuring the day in advance is a vital way of managing lockdown. Try to connect digitally or by phone with parenting buddies and share your daily schedules. Mentor one another. How did you go today with your plans? (Lots of self-compassion when things didn’t quite work out!) Planning might happen the night before but is best done days ahead, seeking out Zoom activities you might enjoy (and trying to do some of these online activities in the backyard or on the deck for the sake of the baby’s sensory needs, if you have that option). Plan to squeeze in whatever social contact you possibly can, either online or face-to-face within the prevailing covid regulations. Schedule in heaps of opportunities for physical activity.3
Have baby start the day at the same time, as early as possible. As tempting as sleep-ins are when we are already exhausted and facing yet another day in lockdown, getting up at the same time, as early as possible, keeps the setting on everyone’s circadian clock healthy over time. This is where a quick wake-up breastfeed or feed and then sending the baby off with another loving adult for adventures (outside whenever feasible) can be very helpful, so that you can catch up on sleep.
Sort out breastfeeding problems such as fussing at the breast, or breast and nipple pain, with an evidence-based approach if at all possible, since breastfeeding is protective for both you and your baby.14 Breastfeeding makes life easier for women and babies in lockdown, once underlying problems have been addressed. It’s possible to access evidence-based help by finding an NDC-accredited international board certified lactation consultant who works in telehealth. There is also an online self-help programme available at https://education.possumsonline.com/programs/gestalt-breastfeeding-online-program. Breastfed babies might also feed more than usual inside the home, just because this is the most interesting thing going on.
Don’t attempt to set up feed or sleep routines for the baby. Very importantly, the well-meaning advice to try to control or structure the infant’s biological processes of sleeps and feeds can back-fire during lockdown. Sleep training routines may seem attractive at first, with their promise of free time while baby sleeps during the day. It’s natural to have powerful longings for time to yourself, and important to have someone else care for the baby so that you have enough time off duty, if at all possible. But unfortunately, traditional sleep training strategies can make life harder and more stressful, and do not reliably decrease night-waking.15-18
Frequent flexible feeds and establishing a healthy relationship with your baby’s sleep regulators without focusing on naps is best for baby and best for families.20-23 That’s not to say that patterns of feeds and sleeps don’t emerge for some, but these patterns might also change from week to week. Being relaxed about when baby sleeps and feeds is much better for everyone’s mental health.
Be ready to meet your baby’s sensory-motor needs as best you can during lockdown. You might find of interest the podcast available here about meeting a little one’s sensory needs when isolating at home. There is also a video here about protecting the development of your baby’s social skills.
Get physical with the baby when you have to be inside. Babies can cry and fuss a lot inside the home, just because our interior environments are low in sensory experience.24 Changing rooms or bringing in new toys and mobiles are not likely to meet a baby’s sensory needs for long, though you can always try. Carriers and backpacks may prove effective tools throughout lockdown because they offer your baby rich and diverse vestibular stimulation, contact with your body and a changing visual experience even in an interior environment. Try vigorous play down on the floor, exercising with baby resting on your body or your legs while you lie on your back, playing airplanes, lots of dancing, long splashy baths together. If there is another adult working in the house, remind him or her that it’s important to take a five- or 10-minute break from the computer every hour, which can be a whirlwind of physical activity with the baby, helping to fill that little one’s sensory tank.
Spend as much time as possible outdoors or on a deck. In Australia, many of us are lucky enough to have patios or decks and backyards. This is a tremendous advantage during lockdown, and much of your daily life might happen out in the backyard, properly protected against the weather. Even a tiny garden offers your little one a wealth of opportunities for sensory exploration.
If you dwell in an apartment, it’s helpful to orient your activities so you and baby are bathed in as much natural light as possible and can see out the windows, whatever the view. And then spend as much time as you possibly can out walking the streets! Again, we are fortunate in Australia – it’s not often dangerous to take a baby out in the weather.
Some parents run with their baby in a jogging stroller or cycle with baby in a trailer; for many others that’s too daunting. Walking, walking, walking is the easiest way to use every minute of your allocated exercise time outside the house with the baby. If you are allowed to walk with a (socially distanced) friend, plan ahead for that.
In recent years, research has confirmed the positive effects of green spaces on infant development and adult mental health.25, 26 Use whatever access you have to parks and the natural environment during lockdown – your baby will love it, and it’s good for you, too.
Mealtime offers rich sensory explorations for an older baby. Remember that for a baby older than six months, introducing solids becomes a wonderful sensory adventure. This is not the time to fret about tidiness: get the plastic mats out and let your little one relish in tastes and textures and squishy mess. This too helps fill her sensory cup.
Remember that you and your baby are remarkably resilient. From an evolutionary point of view, mothers and babies have always been incredibly adaptive across highly variable cultural practices and life experiences. This is the power of human neuroplasticity, innate to both your own and your baby’s brain. You might not be feeling much love and warmth towards your baby in the exhaustion of lockdown, but it’s your behaviour that matters to her: your feelings of love and warmth will come later, when life is less stressful. Your baby may not be getting much of certain social and sensory experiences right now, no matter how hard you try, but she will drink it all in later on, once circumstances change.
Gently allowing your attention to fall back into the present moment, over and over, minute by minute, taking one tiny action after another: that’s how a woman gets through lockdown with her baby.
|What does high-level evidence tell us a new mother requires for protection of her mental health during lockdown?|
|Adapted from Suwalska et al J Clin Med 20213|
Social support (seeking this out online, and as much F2F as possible within regulations)
Partner emotional support
Use of online platforms and telehealth
Access to outdoors
Dr Pamela Douglas is a GP and Medical Director of Possums & Co. www.possumsonline.com, a charity that educates health professionals in the evidence-based Neuroprotective Developmental Care (NDC) or Possums programs, including the Possums Baby and Toddler Sleep Program. If you wish, you can refer to or upskill to become an NDC-accredited practitioner. There are lots of free videos and other resources for parents with babies here, and online parent peer support is available for a nominal fee. Pam is an Associate Professor Adjunct with the School of Nursing and Midwifery, Griffith University, and senior lecturer with the primary care clinical unit, The University of Queensland. She is author of The Discontented Little Baby Book: all you need to know about feeds, sleep and crying.
- Hessami K, Romanelli C, Chiurazzi M, Cozzolino M. covid-19 pandemic and maternal mental health: a systematic review and meta-analysis. The Journal of Maternal-Fetal & Neonatal Medicine. 2020:doi:10.1080/14767058.14762020.11843155.
- Iyengar U, Jaiprakash B, Haitsuka H, Kim S. One year into the pandemic: a systematic review of perinatal mental health outcomes during covid-19. Frontiers in Psychiatry. 2021:doi:10.3389/fpsyt.2021.674194.
- Suwalska J, Napierala M, Bogdanski P. Perinatal mental health during covid-19 pandemic: an integrative review and implications for clinical practice. Journal of Clinical Medicine. 2021;10:2406.
- Lewis K. Coronavirus: perinatal mental health services demand more than doubled in lockdown. The Canberra Times: 2020.
- Scarff J. Postpartum depression in men. Innovations in Clinical Neuroscience. 2019;16(5-6):11-14.
- Brown JVE, Wilson CA, Ayre K, Robertson L, South E, Molyneaux E, et al. Antidepressant treatment for postnatal depression. Cochrane Database of Systematic Reviews. 2021;2(2):CDO13560.
- Molyneaux E, Trevillion K, Howard LM. Antidepressant treatment for postnatal depression. JAMA. 2015;313(19):1965-1966.
- Lewis S. Four research papers I wish my GP had read before prescribing antidepressants. British Journal of General Practice. 2021:https://doi.org/10.10.3399/bjgp3321X716321.
- Davies J, Read J. A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: are guidelines evidence-based? Addictive Behaviors. 2019;97:111-121.
- Howard LM, Molyneaux E, Dennis C-L, Rochat T, Stein A, Milgrom J. Non-psychotic mental disorders in the perinatal period. Lancet. 2014;384:1775-1788.
- Bonacquisiti A, Cohen M, Schiller CE. Acceptance and commitment therapy for perinatal mood and anxiety disorders: development of an inpatient group intervention. Archives of Womens Mental Health. 2017;20:645-654.
- Waters CS, Annear B, Flockhart G, Jones I, Simmonds JR, Smith S, et al. Acceptance and Commitment Therapy for perinatal mood and anxiety disorders: a feasibility and proof of concept study. British Journal of Clinical Psychology. 2020;59:461-479.
- Whittingham K, Douglas PS. “Possums”: building contextual behavioural science into an innovative evidence-based approach to parenting support in early life. In: Kirkaldy B, editor. Psychotherapy in parenthood and beyond. Turin, Italy: Edizioni Minerva Medica; 2016. p. 43-56.
- Singh AP, Kumar VHS, Panda S. Supporting breastfeeding in 2021 and beyond – lessons from the pandemic. Paediatric Reports. 2021;13:289-301.
- Kempler L, Sharpe L, Miller CB, Bartlett DJ. Do psychosocial sleep interventions improve infant sleep or maternal mood in the postnatal period? A systematic review and meta-analysis of randomised controlled trials. Sleep Medicine Reviews. 2016;29:15-22.
- Douglas P, Hill PS. Behavioural sleep interventions in the first six months of life do not improve outcomes for mothers or infants: a systematic review. J Dev Behav Pediatr. 2013;34:497–507.
- Bryanton J, Beck C, Montelpare W. Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database Syst Rev. 2013(11):CD004068. DOI: 004010.001002/14651858.CD14004068.pub14651854.
- NHMRC. Report on the evidence: promoting social and emotional development and wellbeing of infants in pregnancy and the first year of life. http://www.nhmrc.gov.au: Australian Government, 2017.
- Brown A, Lee M. Breastfeeding is associated with a maternal feeding style low in control from birth. PLoS One. 2013;8:e54229.
- Ozturk M, Boran P, Ersu R, Peker Y. Possums-based parental education for infant sleep: cued care resulting in sustained breastfeeding. European Journal of Pediatrics. 2021:DOI: 10.1007/s00431-00021-03942-00432.
- Ball H, Douglas PS, Whittingham K, Kulasinghe K, Hill PS. The Possums Infant Sleep Program: parents’ perspectives on a novel parent-infant sleep intervention in Australia. Sleep Health. 2018;4(6):519-526.
- Ball H, Taylor CE, Thomas V, Douglas PS, Sleep Baby and You Working Group. Development and evaluation of ‘Sleep, Baby & You’ – an approach to supporting parental well-being and responsive infant caregiving. Plos One. 2020;15(8): e0237240.
- Douglas P, Miller Y, Bucetti A, Hill PS, Creedy D. Preliminary evaluation of a primary care intervention for cry-fuss behaviours in the first three to four months of life (“The Possums Approach”): effects on cry-fuss behaviours and maternal mood. Australian Journal of Primary Health. 2013;21:38-45.
- Douglas PS, Hill PS. A neurobiological model for cry-fuss problems in the first three to four months of life. Med Hypotheses. 2013;81:816-822.
- Gianfredi V, Buffoli M, Rebecchi A. Association between urban greenspace and health: a systematic review of the literature. international Journal of Environmental Research and Public Health. 2021;18(10):5137.
- Islam MZ, Johnsotn J, Sly PD. Green space and early childhood development: a systematic review. Reviews on Environmental Health. 2020;35(2):189-200.