Guide to Depression during Pregnancy
Authored by:
Anna Glezer, M.D.
Many of my patients are surprised to hear how common it is to experience depression during pregnancy. Perhaps this is because pregnancy in today’s society is often viewed as almost a magical time for a woman, full of glowing happiness. However, for many women, this is not the case.
Depression during pregnancy, called antenatal, prenatal, or perinatal depression, happens to 10-15% of women. Depression after delivery, called postpartum depression, happens to 15-20% of women. While there has been more public awareness recently about this postpartum condition, depression during pregnancy is often overlooked and under-diagnosed.
Why Do Women Experience Depression during Pregnancy?
There are several theories explaining why depression is so common during this time. The first is that depression overall is more common in women, with 1 in 5 women struggling with the illness over the course of a lifetime. And, the average onset for depression in women corresponds with prime reproductive years. Pregnancy is an extremely stressful event and can trigger illness in someone who has a vulnerability to depression due to biological, genetic, environmental, or other reasons.
The second theory is that the hormones of pregnancy predispose women to developing depression. This includes the gonadal hormones of estrogen and progesterone, as well as the stress hormone, cortisol. [See my article on Hormones in Pregnancy for further information on these hormones].
Risk Factors for Perinatal Depression
It is essential to recognize perinatal depression because it can have significant negative outcomes on the pregnancy, both for mom and baby. In order to treat it and decrease the potential for these consequences, we must first be able to diagnose it and understand who is predisposed to this condition.
A number of risk factors predispose to depression in pregnancy. If you have any of the following, you could be at higher risk:
History of prior depression
An unplanned pregnancy
Poor social support
Marital conflict, including poor communication or low emotional support
Problems at home including domestic violence
Medical complications like high blood pressure
One strong predictor of relapse of depressive symptoms during pregnancy is discontinuation of medication. Many women have told me that upon learning they are pregnant they quickly stop taking their antidepressant medication – sometimes on their own, other times on the advice of their psychiatrist or obstetrician. Abruptly stopping medication can lead to a relapse of symptoms in pregnancy in over two-thirds of women, a rate much higher than if a woman continues in treatment.
Diagnosis of Perinatal Depression
The reason pregnancy-related depression is more challenging to recognize and diagnose relates to the symptoms of depression. In the diagnostic manual, DSM V (used by mental health clinicians to diagnose conditions from depression to anxiety to schizophrenia), the definition of depression is: a period of low mood or irritability that lasts nearly all day for at least two weeks, along with a decrease in pleasure. To make the diagnosis, several other symptoms are evaluated: sleep, appetite, energy, concentration, and several others. You might see why this is more challenging in pregnancy. Sleep, appetite, energy, and concentration by the very nature of pregnancy are altered! This is one reason almost two-thirds of women experiencing an episode of depression in pregnancy are missed or misdiagnosed.
One tool I use daily in my clinic for screening is called the Edinburgh Post-Natal Depression Scale. It is a 10-item questionnaire that was originally developed for postpartum women, but whose questions fit pregnant women as well. You can take a look at this screening tool here.
Adverse Outcomes of Perinatal Depression
The consequences of untreated depression in pregnancy can be far-reaching, affecting labor/delivery, infancy, and beyond:
Increased risk of pre-eclampsia
Lower birth weight babies and smaller for gestational age babies
Preterm delivery
Worse prenatal care follow-through, including poorer nutrition
Increased risk of substance use, wherein a woman might turn to smoking or alcohol or another substance to self-medicate the symptoms of depression. These substances in turn affect the developing baby and delivery outcomes
More severe nausea in pregnancy
Higher rates of sick leave during pregnancy
Impaired neurodevelopment of the baby and worse cognitive functioning, along with differences in infant neurochemistry and neuro-electrical activity. For example, infants are less active, more irritable, with less facial expression
Higher risk of postpartum depression in mom
Decreased rates of breastfeeding initiation
Higher rates of admission to the neonatal intensive care unit (NICU)
For all these associations, it is imperative to recognize depression during pregnancy and seek treatment. There are many treatment options, some involve medications, and others include light-therapy, psychotherapy, and complementary and alternative modalities. Over time, I will be posting articles on all of these to help you decide which fit your values, needs, and symptoms best.
The good news is that pregnancy related depression is quite responsive to treatment. I work with many women who begin to feel better quickly and are able to enjoy their pregnancy and beyond.
Selected References:
Gentile, S. Untreated depression during pregnancy: Short- and Long-term effects in offspring. A systematic review. Neuroscience 2015.
Cohen, L.S. et al. Relapse of Major Depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA (2006) 295(5): 499.
Grote, N.K., Bridge, J.A., Gavin, A.R. et. al. A meta-analysis of depression during pregnancy and the risk of preterm birth, low birthweight, and intrauterine growth restriction. Archives of General Psychiatry (2010) 67(10):1012-1024.
