Depression in Pregnancy

It is a well established fact that the time after birth or the postpartum period is a vulnerable time for women to become depressed. For decades the medical profession believed the increased hormones in pregnancy protected women from becoming depressed. This belief supported society's myth that ‘every pregnant woman is happy because she is forming a new life'. The fact that a woman can be depressed during pregnancy is relatively new and therefore the illness largely goes undiagnosed at the time. In the late 70's and 80's researchers discovered that many of the women who experienced depression after the birth of their child were depressed in pregnancy.

Today we know that 10 % of women will experience depression during pregnancy.

What does depression in pregnancy look like?

A woman is diagnosed with depression if she experiences these disturbing moods, feelings, and behaviors nearly every day for 2 weeks that significantly interfere with her ability to care for herself, her other children, her home and her work.

• Depressed mood or extreme sadness
• Crying spells for no apparent reason
• Guilty thoughts or feelings of worthlessness or hopelessness
• Restlessness, lack of control, or lack of energy
• Difficulty concentrating or disorganized thoughts
• Feelings of guilt or inadequacy as a mother-to-be
• Changes in sleep or appetite e.g. sleeping or eating too little or too much
• Withdrawing from partner, family, friends, co-workers
• Thoughts of suicide or other frightening thoughts of hurting others

Feeling sad, negative, angry and anxious while pregnant is so paralyzing that most women are unable to talk about it. Their silence makes diagnosing depression in pregnancy difficult. Their experience of depression is so far from the image of ‘an ideal pregnancy' that they cannot imagine anyone believing or understanding how they feel. They are ashamed that they are already bad mothers. These thoughts may reoccur and trigger a spiral into a deeper depression for women.

When women find a way to talk about their feelings, care-givers may have difficulty diagnosing depression because the symptoms of pregnancy mimic the signs of depression. Symptoms of pregnancy and depression are most similar in the first trimester of pregnancy (from the day that your last menstrual period began until 12 weeks) and the third trimester (24 weeks until 40 weeks). These are the times when women experience the most uncomfortable physical symptoms. In the first and third trimester pregnancy women are tired, may have difficulty eating or sleeping, and are physically uncomfortable. The most dramatic changes in hormones also occur during these two trimesters. Hormones keep the pregnancy going until the placenta takes over, regulate glands, prepare for labour and delivery and milk production. These changes in hormones may trigger women to experience rapid mood changes. Consequently, they may be more irritable, weepy, anxious, angry and agitated during the first and third trimesters.

The second trimester (from 12 weeks to 24 weeks) is a time when most women have adjusted to the hormonal changes and the baby's first movements are felt. Women typically feel better during this time. Therefore, women who talk about uncomfortable physical or emotional symptoms during this trimester are usually diagnosed more quickly.

Factors that Contribute to Depression in Pregnancy

There are different factors that may contribute to the development of depression in pregnancy. Some women may have a genetic predisposition to developing depression. Women whose blood relatives were depressed, especially if they had postpartum depression, are at risk of developing depression in pregnancy. A third of women who experienced depression in their teens or during their young adulthood years will have another episode of depression during pregnancy. More than half of the women who were depressed after the birth of a baby will experience depression during their next pregnancy. Some women may also be more vulnerable if they are experiencing an unwanted pregnancy. The opposite may also happen. A woman who has been infertile and finally becomes pregnant may also be at greater risk of depression due to fluctuations in hormone levels that occur while attempting to get pregnant, followed by the hormonal changes in pregnancy.

Other factors that make women most vulnerable to developing depression in pregnancy are: being in a relationship that is perceived as unsupportive, lack of other social supports, being isolated, a past history of abuse or violence, drug and alcohol abuse/dependence and having experienced recent stressful live events (such as the death of a parent, moving or changing jobs). For some vulnerable women, the normal stresses of becoming a mother, such as the added responsibility or financial stresses may be enough to cause them to feel both anxious and depressed.

Dr. Shaila Misri a psychiatrist in the Reproductive Mental Health Program (RMHP) at British Columbia's Women's Health Centre states,

"Few care givers and women understand that pregnancy can trigger a depressive episode. Some of these women may have an undiagnosed depression or panic disorder. As early as 2 weeks into the pregnancy they can have severe depressive symptoms: crying spells, not sleeping, loss of interest in life, and panic attacks."

Sara had multiple factors that caused her to become depressed during her pregnancy. She had an undiagnosed and untreated postpartum depression with her first child, followed by 2 miscarriages. She became depressed in the first trimester of her subsequent pregnancy. Fortunately, Sara was connected to a Pregnancy Loss Program, and was referred to the Reproductive Mental Health Program where she received supportive counseling. The demands of work, a loss in the family and the approach of the 14 week- point when she lost her previous pregnancies, caused her anxiety to rise. She was started on medications and she continued with counseling and medication throughout the remainder of her pregnancy and into the postpartum period. Sara did well on this treatment.

Why Depression in Pregnancy Should be Treated.

Women who are depressed during pregnancy are more likely to avoid prenatal care, therefore not receiving adequate care. They may not sleep or eat well. These factors plus the stresses accompanying depression may cause medical difficulties in pregnancy, such as, premature labour, and small birth weight infants. Women who struggle with troubling thoughts and feelings of despair may use alcohol or drugs to cope, with potential serious consequences to their baby's health.

If left untreated, depression in pregnancy will likely get worse, leaving the woman vulnerable to becoming even more depressed following the birth of her baby. A severe postpartum depression may take longer to respond to treatment and may effect how the mother interacts with her infant. Research indicates that depressed mothers have more negative face-to-face interactions with their babies, have less eye contact during feeding, are less playful and are more withdrawn than non-depressed mothers. Infants of depressed mothers typically look away, react with more crying, sadness and fussiness, and have more trouble sleeping. The negative effects of the depression on the infant will be lessened if the woman receives treatment early. Treating depression in pregnancy will reduce the risk of developing a postpartum depression.

How Women Can Help Themselves

Women who experience a mild form of depression may see an improvement with changes to their lifestyle that increase their body's ability to cope with the stresses. Lifestyle changes that will help women cope are:

• maintaining proper nutrition and diet by eating more vegetables, fruits, vitamin-rich foods, and drinking more water
• avoid all alcohol: remember alcohol is a depressant and is dangerous to the developing baby
• getting regular exercise; this produces endorphins (mood enhancers) that help combat fatigue, lethargy and sleep disturbances
• maintaining a regular sleep-wake pattern
• using stress management techniques such as yoga, relaxation exercises, time management skills, etc.

These strategies alone may not be enough to recover from depression. Women may need counseling and/or medication.

Getting Help

Because of the overlapping symptoms of pregnancy and depression you may need to talk to your family physician not only once but several times about some of the following:

• How strong your emotions are e.g. how sad you feel.
• How often you have these emotions e.g. how often you cry.
• How your emotions are affecting your life, your ability to take care of yourself, your home, work or your interactions with your partner, family and friends.
• How much you are sleeping or eating- very little or too much.
• Whether you have had any feelings of hopelessness and suicidal thoughts.

Remember your physician does not know what you are thinking and how you are spending your days. You need to talk freely and openly about your behaviors, feelings and thoughts - even though they may scare you. It may help to bring this fact sheet to your next appointment to start the discussion. If you are having suicidal thoughts and your physician is not available, go to the nearest emergency and discuss these fears.

Linda King a counselor with the Pacific Postpartum Support Society talks about being depressed during and after her 1st and 3rd pregnancies. When asked why she did not seek help when depressed and pregnant for the second time Linda answered,

"Even though I received treatment after the birth of my first child, I still didn’t have a clear picture of what depression in pregnancy looked like. I kept thinking it was just me. What I saw were mothers that were able to cope. So I did too. At work and socially I ‘looked like’ I had it all together. Keeping up this appearance while I was depressed and pregnant took all my energy so when I got home and closed the front door I would Eventually ‘hit the wall’. I was irritable and angry."

Today Linda is passionate about helping other moms who are depressed.

"If I can help just one woman from feeling as awful as I did, freeing her to enjoy her kids and be kinder to her husband, I am very happy."

Linda encourages women who have had postpartum depression to seek help as early as possible in their next pregnancy.

Treating Depression in Pregnancy

Women who experience a more severe depression may need counseling and/or medication. Counseling women with depression during pregnancy includes educating them about their illness, providing reassurance, supporting them in identifying patterns of negative thinking and assisting them to develop strategies to cope with this stressful time. With more severe depression or when counseling does not decrease the symptoms of depression, the family physician or psychiatrist may prescribe medication. This always involves weighing the risks versus the benefits of medication.

In the last decade new medications and research has shown that some antidepressant and antianxiety medication can be used during pregnancy with minimal to no effect on the fetus. The risks of using medications versus the risks of not using medication needs to be discussed. This will enable the woman to make an informed decision. As a rule medications are avoided during the first trimester of pregnancy when the fetus is developing the most. Remember if medications are prescribed it may take 4 to 6 weeks to know if they will begin to work. Medications should not be stopped unless you talk to your physician. Medication needs to be gradually reduced and not stopped suddenly or severe symptoms of discontinuation or of the original depression, such as suicide, may return.

Even with treatment a woman's symptoms of depression will fluctuate during pregnancy. She may improve, then have more symptoms and then improve again. However, we do know that a woman will often get worse after the baby is born if she is left untreated. With treatment most women recover completely. Unfortunately, for a very small number of women this episode of depression may mark the beginning of a long lasting mental illness. Without treatment, women may continue to struggle silently with their depression for years.

Partners and others can support women who are depressed during pregnancy by listening to their concerns, holding them and comforting them. Women may want someone to go with them to their doctor's appointments, or they may need more practical help with daily chores around the house, such as cooking or cleaning. Depressed women who have other children will need additional help from their partners, family and friends.

In summary, most women who experience depression in pregnancy and receive treatment do improve. They do better after their babies are born and are better able to meet their own needs and their babies' needs. Once recovered, many of these women who have struggled with their depression may talk openly about how the experience has changed their lives, by making them face old fears and issues and strengthening their supportive relationships.

Sources:

• BC Reproductive Mental Health Program. "Best Practice Guidelines: Principles of Early Identification, Assessment, Treatment and Follow-up of Women with Mental Illness during and after Pregnancy".
• Woman's Moods: What every Woman Must Know about Hormones, the Brain and Emotional Health by Deborah Sichel and Jeanne Watson Driscoll, ISBN 0-688-14898-0,1999, William Morrow & Company. Inc., New York Pacific Postpartum
• Support Society. Postpartum Depression and Anxiety: A Self-Help Guide for Mothers . 7^th edition. Vancouver: PPPSS, 1977.