The intersection of mood disorders and gestation
by Tara Haelle
After my second child was born, I figured I would be ready for the hormonal roller coaster that turns laughter into sobs and ravenous hunger into a total repulsion for food. I knew those “baby blues,” which affect up to four out of every five women, were largely the cruel effects of plummeting estrogen and progesterone while my body tried to remember what it was like not to incubate a baby. Alas, it hit me hard all the same. Each time I awoke to feed the baby, I was shivering with cold yet drenched in sweat. I couldn’t focus on something as simple as a TV sitcom. I walked into the bathroom and forgot I was there to pee. I tried to ask my son’s pediatrician a question and instead randomly started bawling.
In fact, my daily crying was almost predictable, like those mountain towns where it rains at the same time every day. I knew, though, that these symptoms – the irritability, mood swings, crying, concentration problems – would fade for the most part after a week or so, and they did. Most baby blues resolve by the tenth day postpartum or so, give or take. But I was still vigilant about how I was feeling: my mental health history put me at higher risk for any of the more serious mental health conditions that can accompany pregnancy and the postpartum period, and baby blues can often be warning signs for who develop those conditions.
Most women have heard of postpartum depression, though it may evoke for them the horror stories of women drowning their children or driving them off a bridge. Such severe extreme cases of postpartum psychosis are exceedingly rare – just 1 in 1,000 women. But postpartum depression without psychosis is much more common – the most common complication with pregnancy, in fact – and it’s not the only mental disorder associated with pregnancy. The others include prenatal depression, postpartum anxiety (or panic) disorder and, though much rarer, postpartum obsessive-compulsive disorder. And we can’t forget the dads: they can experience prenatal and postpartum depression as well.
I want to emphasize: these are real medical conditions. It makes no more sense to say depression is “all in your head” than it does to say diabetes is just “all in your kidneys” or atherosclerosis is “all in your arteries.” Of course it’s in your head, and it means you need treatment. You shouldn’t ignore prenatal or postpartum depression, expecting it will eventually just “go away.” It might, but most likely it won’t, which could cause more mental and physical health problems for you and your family. Depression has been linked to heart disease, diabetes, insomnia, obesity, and other chronic conditions, but untreated prenatal and postpartum mental conditions may also have ramifications for your children.
Mental health conditions related to pregnancy and the postpartum period probably affect about one in ten women (and men), and really, it’s surprising the number isn’t higher. Especially with a first baby, you’re up against a lot: fragmented and insufficient sleep, yo-yoing hormones, forming an attachment with your child, seeing all those ideals about parenthood get shot down one by one, redefining family roles and relationships, establishing a good breastfeeding or bottle feeding routine, struggling with whether you’re an adequate enough parent… Oh, and by the way, now that your body has ejected a parasitic alien creature you’re just beginning to get to know, whee! goodbye old life. First your body is ravaged and now your time is monopolized by a demanding critter who weighs less than most chihuahuas. It can take a toll.
The risk factors for pregnancy-related mental health conditions are similar across the conditions. A personal or family history of depression, anxiety, bipolar disorder or other mental disorders is an obvious risk factor: about half of all women with postpartum depression have a history of a previous depressive episode, and about a quarter to half of all women who experience postpartum depression once will experience it again. Unsurprisingly, women who have experienced domestic violence are at a higher risk for these disorders as well as post traumatic stress disorder. Overweight and obese women may have a slightly elevated risk also: one study found obese women to have 1.4 times greater odds of prenatal depression and 1.3 times greater odds of postpartum depression.
A number of things might increase your risk of a mood disorder, though not all of these are agreed-upon risk factors: anxiety in pregnancy, gestational diabetes, having multiples (twins, etc.), being younger and/or a first-time mom, experiencing relationship or financial problems, having an unplanned or unwanted pregnancy, lacking a support system, recent stressful life events or stressful events during the pregnancy or delivery, having unrealistic expectations of parenthood, a history of severe PMS, and, for those with a history of depression, insomnia during pregnancy.
Prenatal Depression and/or Anxiety
Woohoo! You’re pregnant! You’ve been trying for a baby and have that “pregnancy glow” and are super excited and – what? You’re depressed? Yea, you very well could be. While most people have heard of postpartum depression, many may not have heard of prenatal depression, even though it’s about as common as its post-birth counterpart (from 7–14%). This happened to me, who tried for nearly a year to become pregnant with my second son, was thrilled to see the two little blue lines on the pee stick and then spent my first trimester and part of my second deeply depressed even though I was excited about having another child. Part of the depression had to do with first trimester anxiety, that wait to see if the baby makes it to the second trimester. Part of it had to do with some life circumstances at the time, and part of it likely stemmed from past mental health history.
But what compounded the depression was my (all-day) morning sickness and the frustration of feeling like I was “supposed” to be happy because of my wanted pregnancy. Having an unwanted pregnancy is indeed a risk factor for prenatal depression, but even women who desperately wanted their pregnancy can experience depression. Yet they may not recognize it for what it is if they haven’t heard of it. Several of the symptoms, such as sleep disturbances, appetite changes, fatigue and decreased sex drive, are common in pregnancy anyway, but these will usually be accompanied by feelings of guilt and hopeless, poor self-esteem, an inability to enjoy yourself and suicidal thoughts.
What makes prenatal depression additionally tricky is the uneasiness many women have about taking antidepressants while pregnant, even though the risks to the fetus from antidepressants aren’t clearly established (and may be more related to the mom’s depression or anxiety). In fact, many women’s prenatal depression might actually be a relapse if they discontinued their antidepressants before becoming pregnant. I actually tried this while trying to conceive: I attempted five or six times to wean off of escitalopram under the guidance of my doctor before I became pregnant. Eventually, my husband and I decided that my inability to function once the dosage dropped too low wasn’t worth the tradeoff. And I likely would have ended up back on the meds anyway: one study found that women who stopped taking antidepressants before pregnancy were five times more likely to relapse while pregnant compared to women who continued taking them.
Even among women who continue taking antidepressants while pregnant, about a quarter of them will relapse, as I did. One possible reason for this involves the changes in a woman’s blood volume, liver metabolism and kidney functioning while pregnant, all of which can affect drug levels in the blood. Some studies have found a drop in blood levels of tricyclic antidepressants of up to 65% during pregnancy. It’s possible that the appropriately therapeutic dose you were taking before pregnancy is insufficient when you’re pregnant. Some women may therefore need to increase or otherwise tweak their dosage of tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs) while pregnant – always under the guidance of their doctors. (If I’d known this while I was pregnant, I would have talked to my doctor about my dosage and possibly suffered less.)
In deciding whether taking medication is worth the risk, women also have to consider the risks posed by untreated depression and anxiety, such as poor nutrition, inadequate or excessive weight gain, poor prenatal care and substance use – all of which can negatively impact the fetus. Further, prenatal depression can greatly increase the likelihood that a woman will experience postpartum depression and all the consequences for her and her family that come with it. Even the depression and anxiety itself – without other factors – can have a negative impact on a fetus. One research review found an increased risk for miscarriage, preterm labor and a malformed newborn among women with high stress or anxiety levels during pregnancy, and another found a higher risk for preterm birth and obstetric complications.
Treatment for prenatal and postpartum mental conditions can be more problematic than that for non-pregnancy conditions because of the uncertainties about medication and its effects on the child. As noted above, for those already taking medication, it may be necessary to tweak the dosage in light of physiological changes during pregnancy that can affect the medication blood levels.
For women without a history of previous depression, and/or with mild to moderate depression or anxiety, medication may not be necessary, or at least not right away. Cognitive behavioral therapy, interpersonal therapy or other forms of individual or group therapy are best to try first. If therapy fails or is not an option, then women may need to consider medication. Some research has looked at estrogen therapy as a treatment, but the findings have been inconclusive, and estrogen can affect breastmilk production and increase the risk of blood clots.
So far, light therapy has not been shown to treat postpartum depression successfully, and the jury is still out on acupuncture, yoga and exercise since there are too few data to assess them. However, in conjunction with therapy and/or medication, exercise, sunlight, yoga, a balanced diet, sufficient water intake and a balanced diet may all help.
The bottom line is that depression is a medical condition that requires treatment, even if it occurs during pregnancy.