Depression And Pregnancy
Pregnancy is a wondrous moment. It is the time when women are excited to be called “moms.” It is a great opportunity to learn about child’s growth and development. But sometimes it can be the other way around. Pregnancy is not always such a happy experience for some. Pregnancy can also be a time for worry. It can also be a moment of confusion.
A woman’s decision to begin a pregnancy carries with it the acceptance of the lifelong responsibility to be a parent. Ideally, effective parenting begins even before the moment of conception, when the woman confirms her desire to have a child and is physically and mentally prepared for the challenges of pregnancy, birth, and parenting.
However, most women go through a lot of changes during pregnancy, sometimes it is causing them stress as well as numerous emotional and physical changes. As a result, many pregnant women develop depression during their pregnancies.
Depression is the most common psychiatric disorder, so it’s a commonly encountered pre-existing condition during pregnancy. Depression has both physiological as well a sociological causes. It is actually caused by a number of different factors. But, it is most likely to be linked to a change in the levels of chemicals in the brain. These chemicals govern our moods, and when they become disrupted, it can lead to depression.
During pregnancy, the rapid change in a woman’s body’s hormones can trigger a change in the levels of these chemicals, resulting in depression. Interestingly though, women have it twice as often as men, and among women, there is an increased tendency toward it during the reproductive years.
It has been proven that the rapid rise in hormone levels during pregnancy is actually a very common trigger for depression. At least 20% of pregnant women experience some depressive symptoms during their pregnancies, while 10% of pregnant women develop full-blown clinical depression. Depression during pregnancy is actually much more common than many people realize. At one time, health care professionals thought that pregnant women couldn’t suffer from depression because of their pregnancy hormones. It was believed that these hormones protected against mood disorders like depression.
Any pregnant woman can develop depression at some point throughout her pregnancy. There are several causes of it during pregnancy, some of which are the following:
- having a personal or family history of depression
- relationship or marital conflict
- age at time of pregnancy
- unplanned pregnancy
- living alone
- limited social support
- previous miscarriage
- pregnancy confusions and complications
- history of emotional, physical or sexual abuse
Because depression can often drain a woman’s desire and energy, pregnant women with the disorder may not seek appropriate prenatal care. Depression during pregnancy may also increase the likelihood that a pregnant woman will abuse alcohol, cigarettes, or drugs during pregnancy. When it is most severe, clinically diagnosed depression can be a psychiatric emergency. Because a woman is in a very difficult period of adjustment and less likely to climb out of her despair, hopelessness, and suffering, she poses a danger to herself and her new baby.
Pregnancy is a particularly active field for depression to either start anew or worsen if already a problem. The extra physical, financial, marital, and sexual stresses come whether one is ready or not. On top of that, any new feelings of poor self-image can reinforce depression’s already negative self-image problems.
Preparing for a new baby is a lot of hard work, but a woman’s health should come first. A pregnant woman should resist the urge to get everything done, she should limit her activities and do things that will help her relax. Talking about things that concern a pregnant woman is also very important during these difficult times. A pregnant woman should ask for support, which most often than not, she will get. Remember that taking care oneself is an essential part of taking care of the unborn child.
Across the US, prevalence studies show that one in five women will experience an episode of major depressive disorder (MDD) during their lifetime. The onset of depressive symptoms is most often seen between 20 to 40 years old, the age range when many women become pregnant.
Studies have shown that 10 to 16% of pregnant women fulfill the diagnostic criteria for MDD, and even more women experience subsyndromal depressive symptoms, which are frequently overlooked.
Because of this correlation with life events, it is very important for healthcare providers to be aware of:
- the frequency of depression in this population,
- signs, symptoms and appropriate screening methods, and
- health risks for the mother and growing fetus if depression is undetected or untreated.
A study by Marcus and colleagues in 2003 found that of pregnant women screened in an obstetrics setting who reported significant depressive symptoms, 86% were not receiving any form of treatment. While most women seek some prenatal care over the course of their pregnancy, many women do not seek mental health services due to stigma; thus, antenatal visits to an obstetrician or primary care provider may provide an opportunity for screening and intervention for depression in this high risk group.
Since management of the depressed, pregnant woman includes care of her growing fetus as well, treatment may be complicated and primary care providers should consider a multidisciplinary approach including the obstetrician, psychiatrist, and pediatrician to provide optimal care.
Unidentified and untreated depression can lead to detrimental effects on the mother and child. Suicide is the most catastrophic effect of undertreated depression. In addition, depressed women are more likely to participate in unhealthy practices during pregnancy such as smoking and illicit substance abuse.
These women have higher rates of poor nutrition, in part due to a lack of appetite, leading to poor weight gain during pregnancy and risking intrauterine growth retardation. Depressed women are less compliant with prenatal care and feel less invested in the care toward their pregnancy.
Finally, women with depression have increased pain and discomfort during their pregnancies, reporting worse nausea, stomach pain, shortness of breath, gastrointestinal symptoms, heart pounding, and dizziness compared to non-depressed women.
Treatment of Depression During Pregnancy
There are few current medical standards for treatment of women with depression during pregnancy, in part because ethical constraints preclude randomized controlled trials using pharmacotherapy during gestation. Some women do not seek treatment, but for those who do, many physicians are unsure of how to balance maternal medication needs with risk of exposure to the growing fetus.
Because many pregnancies are unplanned and undetected for some time, all women of childbearing age should have their depression managed as if they are or will become pregnant. The primary care provider should engage in preconception planning with all women of childbearing age who have or are at risk for depressive illness. Treatment planning with regard to the use of pharmacotherapy during conception and the first trimester is among the most important decision points for a woman and their physician. Women diagnosed with depression who have been asymptomatic for over a year may wish to attempt to reduce or discontinue their antidepressants a few months prior to conception and throughout the pregnancy; however, one study found that 60% of women taking antidepressants at the time of their baby’s conception had depressive symptoms over the course of the pregnancy.
Women should be closely monitored for relapse of depressive symptoms. Sixty-eight percent of women who discontinued their antidepressants during pregnancy experienced relapse symptoms, compared with 26% of women who continued their medication regimen [read: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2680254/#R40]. If a woman’s depression history contains multiple relapses or severe symptoms including suicide attempts and multiple inpatient psychiatric admissions, it is recommended that she remain on antidepressants for her own safety, regardless of pregnancy status [read: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2680254/#R38].
Depression And Pregnancy
Primary care providers need to be aware that depression in women during their childbearing years is extremely common. Routine depression screening, particularly at prenatal care visits, coupled with the use of physician collaborators to assist in connecting women with care is paramount.
During prenatal interviews, providers should be aware of risk factors for depression, including previous history of depression and interpersonal conflict. Links have been made between depression during pregnancy and poor pregnancy outcomes such as preeclampsia, insufficient weight gain, decreased compliance with prenatal care, and premature labor.
The literature suggests that overall the risks of SSRIs are small during pregnancy relative to the risk of undertreatment of depression. If depression continues postpartum, there is an increased risk of poor mother-infant attachment, delayed cognitive and linguistic skills, impaired emotional development, and behavioral issues. Longer term, these children are more likely to have emotional instability, conduct disorders, and require mental health services. To prevent these outcomes, postpartum depression screening with the EPDS or simple screening questions should be a priority for postpartum follow-up visits.
Antidepressant treatments, interpersonal therapy, and adjunctive behavioral treatment, as well as involving family in the supportive care of the postpartum woman, are often helpful strategies.
More research is needed to determine the long-term and developmental effects of antidepressant exposure in children occurring during pregnancy and lactation [read: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2680254/].