Prenatal Depression: Why the Occasional Emotional Misery
Pregnancy is supposed to be a time of joy, excitement and optimistic anticipation for that bundle of joy, right? Sadly, for some women, pregnancy and the thought of motherhood cause sadness, feelings of vulnerability, fear, and distress. Considering the prevalence of major depression is two times higher in adult women than men, it’s not surprising, that depression is a common issue during pregnancy. Clinical depression can become evident for the first time during pregnancy and preexisting depression may be exacerbated.
Symptoms of depression including fatigue, sleep disturbances, tearfulness, diminished appetite and libido, to name a few, can mimic common pregnancy symptoms; thus many clinicians, in good faith, may fail to recognize, diagnose and treat depression in pregnancy. This combined with the fact that many pregnant women won’t report “feeling down” to their health care providers because they feel shame or guilt, further limits recognition. These women suffer, wondering why they are feeling so low when other mothers to be, who are clearly elated, surround them. It is unclear why pregnancy may prompt the onset of depression or worsen an existing diagnosis; factors likely include dramatic hormonal shifts and anticipated psychosocial changes.
Risk factors for prenatal depression include a history of depression or anxiety prior to pregnancy, unintended pregnancy, ambivalence towards the pregnancy, lower income and education levels, smoking, living alone, poor relationship, family history of depression, and discontinuation of antidepressants.
Diagnosis of prenatal depression requires that other medical conditions, such as thyroid or metabolic abnormalities be ruled out. Women should be evaluated for illicit and prescription drugs as well as for use of herbal and over the counter products that may exacerbate psychiatric disorders or cause mood changes.
Antenatal depression has implications for mothers and offspring alike. Pregnant women with depression are at higher risk for alcohol, tobacco and drug use, poor weight gain, insomnia, impaired maternal infant bonding, post partum depression and non-initiation of breastfeeding. Suicide is, of course, the most serious consequence. Depression during pregnancy may cause fetal growth restriction, impaired infant language acquisition and psychiatric issues, including depression in offspring. Genetics as well as other environmental exposures are likely causative factors in as well.
What can we do to better identify this condition and alleviate this suffering? First, women should be screened for depression to insure early diagnosis and treatment. While there is no optimal screening tool, direct questions such as “How have you been feeling emotionally?” or “Do you feel overwhelmed? Sad? Depressed? Hopeless? Helpless?” are useful. In fact, pregnancy is an ideal time for this inquiry, since frequent visits are customary.
I think it’s fair to say that most pregnant women have some worry and angst about pregnancy and impeding motherhood at times. The occasional emotional misery is in part due to the physical discomforts of pregnancy as well the uncertainty of what’s to come. It’s important to distinguish these feelings from true clinical depression in pregnancy. I would venture to guess that pregnant women take comfort in knowing they are not alone in their sentiments, however severe.
The good news: the stigma associated with mental illness, including antenatal depression is being lifted. Diagnosis is more readily recognized and accomplished. Treatment prenatal depression is available including lifestyle changes like regular exercise, individualized therapy with a psychiatrist or specialized prenatal therapist, group support and in some cases medication. These tools are paramount when “what you are expecting is not what you expected.”