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Bumps Ahead

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We often talk about pregnancy as a happy time. In fact, historically, people have thought that the hormones of pregnancy are “protective” against depression, creating a period of euphoria and well-being. It’s true that many expectant women feel good throughout their nine months, but recent research tells us that pregnancy can also be an emotionally vulnerable time for women, especially for those who have a history of mental health issues.

The American Congress of Obstetricians and Gynecologists (ACOG) estimates that 14-23 percent of women experience depression during pregnancy. Already, women are at higher risk for depression than men — in fact, according to the National Institute of Mental Health (NIMH), women are 70 percent more likely to experience depression throughout their lifespan than men. The peak prevalence of major depressive disorders for women is during the childbearing years (likely because of the shifts in body chemistry and life transitions) and depression is known as one of the most common complications of pregnancy and the postpartum.

Causes and risk factors

There isn’t a single cause of depression in pregnancy, but for many women a mix of chemical, environmental, and psychological factors is often at play.

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Chemical changes: Many people are aware that hormonal changes in the postpartum period can cause depression, but the body undergoes drastic hormonal changes during pregnancy as well. It’s not clear exactly which hormones are responsible, but these changes can shift brain chemistry in a way that makes an expectant mom more vulnerable to mood disorders.

Personal or family history: If you have a close relative who struggled with mental health issues around pregnancy or the postpartum, you are at an increased risk as well, since there is likely a genetic component to pregnancy depression, just like any other psychological condition.

But by far the strongest risk factor here is your own history of depression. If you’ve experienced depression earlier in your life, you’re more likely to have a recurrence of these symptoms in pregnancy. One 2006 study in the Journal of the American Medical Association found that women with a previous history of depression who discontinued medication during pregnancy were five times as likely to relapse during pregnancy than those who continued treatment. This is why when you’re pregnant (and whether or not you’re currently taking medication), it’s important to work with a therapist and psychiatrist if you have a history of mood disorders.

Life stresses and changes: Not surprisingly, stress and transition — all part of welcoming a new baby — can cause symptoms of depression. For example, if you and your partner are not getting along, or you’re moving or changing jobs, these forces can surface in psychological and physical symptoms.

Other major life stresses that can cause depression are a previous pregnancy loss or infertility treatments; the emotional roller-coaster of these events (even if the end result is a healthy pregnancy) can stir up difficult feelings that take time and attention to process. You may be able to sort through this with your friends and family, but often it’s helpful to see a therapist to navigate these life stresses as well.

The signs

Pregnancy is a period of enormous chemical and psychological change. It’s normal for women to feel tired, sad, or generally preoccupied and worried about what’s to come. This can feel disorienting or confusing, since you (and others, including your partner) may have the expectation that you’d be nothing but positive and glowing about being pregnant. But you won’t know how you’re going to react to these changes until you’re there, and it’s healthy and natural to have mixed emotions.

However, if you experience a combination of the following symptoms, you could be struggling with more than just the average adjustment period to pregnancy.

  • Feeling sad or empty many days of the week
  • Difficulty concentrating
  • Sleeping too little or too much
  • Eating too little or too much
  • Loss of interest in what you used to enjoy
  • Recurring thoughts of death, suicide, or hopelessness
  • Anxiety or irritability
  • Feelings of guilt or worthlessness

If these sound familiar, and they interfere with your ability to function well during the day — for example, at work, or with your older children or spouse — it’s important to seek help.

Can depression affect your baby?

If you’re feeling the symptoms of depression in pregnancy, do not just “tough it out” and power through. Your physical and emotional state is important to you and those around you, but it’s also important to your growing baby. First of all, when you’re feeling depressed, you’re less likely to take good care of yourself (namely, eating well and staying healthy and active). Researchers have found that depression and anxiety in pregnancy are also associated with low birth weight and premature delivery.

Treatment

The first step is to make contact with a therapist, psychiatrist, or both. You can do this through your OB, or by way of a referral through friends or family. There are clinicians who specialize in helping women in pregnancy and the postpartum (often known as a specialty in perinatal mental health). Unless you already have an existing relationship with a therapist, it’s a good idea to look for someone to talk to who is specialized.

This is also important when it comes to choosing a psychiatrist if you are considering medication — in fact, if you’ve had a psychiatrist in the past, you may still want to consult with one who specializes in perinatal mental health or women’s health. This is in part because of the complex question of medication in pregnancy. A psychiatrist with a women’s health specialty is most likely to have the training and the most current research to help you make a proper risk-benefit analysis when it comes to deciding how to proceed with medication. With mild depressive symptoms and no history of major depression, you might decide with your doctor that talk-therapy or a group-therapy setting is best. On the other hand, if the risks of your untreated depression in pregnancy outweigh the risks of medication, you may decide to continue or start a medication during pregnancy. A significant number of women who experience depression in pregnancy go on to experience postpartum depression, so it’s important to ask for help as early as you can.

What will you discuss in therapy? I asked Stephanie Morales, MFT, a Southern California-based therapist who specializes in perinatal and postpartum mood disorders, about treatment, and she says that in her own practice, she helps women sort out whether their struggle with depression is part of the ebb and flow of hormones (and perhaps they’ve seen this throughout their lives), or whether stress in the environment and relationships is at play. “Most important,” she says, “is to give women a sense that they are not alone — that women all around them are struggling, too.”

Morales says that expectant moms with symptoms of depression and those with a history of mood disorders can seek a specialized therapist through Postpartum Support International, an organization that aims to increase awareness about depression during and post-pregnancy. “A trained perinatal mental provider is a must,” she says. “I’ve seen many things missed because the provider is unaware of the nuances involved in perinatal mental health.”

Whether you decide to use a resource network like PSI, ask your OB for a referral, search online, or put out the word to trusted friends and family, you may be surprised to hear your struggles echoed by plenty of other expectant moms. It can be relieving to find this, and to know that there are many options out there for you in terms of treatment.

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