Mood changes during pregnancy are very common, which makes it harder to figure out what is normal and what is not. However, pregnancy does not protect us from other diseases, and depression is no exception. In my experience, women with depression in pregnancy often feel a huge amount of guilt; in other words, women feel bad about feeling bad. This guilt makes it even harder to seek care and discuss these feelings. In short, many women are undiagnosed and untreated.
Depression during pregnancy and in the post-partum (after delivery) period is very common. While the numbers vary, studies estimate that 14% to 23% of women will experience depression at some time from conception to birth, and 11% to 32% of women will experience depression from birth to three months postpartum. I think it is very important to point out that approximately one of five women will have depression during the pregnancy itself. There has been much attention in the news media to depression after pregnancy; we must be aware that depression is nearly as common during pregnancy, and both groups of women deserve evaluation and treatment.
Many of my patients are very concerned about their mood changes, but are equally concerned about taking medication for these symptoms. It is important to recognize that medications do have side effects and risks. What many women do not know is that untreated depression also has risks to the pregnancy, including impaired judgment, possible self medication with alcohol or drugs, poor appetite or weight gain, insomnia, worsening depression with risk of harm to oneself or others, impaired maternal-infant bonding, and risk of postpartum depression. My best recommendation is to discuss ALL your concerns with your health care provider, so you both can assess the risks and benefits of the symptoms and the treatment options.
Post Partum Depression
Sleep deprivation, the dramatic changes and stresses that accompany motherhood, and shifts in hormones all seem to have a hand in postpartum depression. Physical discomfort, a colicky or sick baby, financial hardship, and scant social support may also be factors. Postpartum depression has many features in common with major depression. A new mother can become sad or hopeless. You may be anxious and especially worried about the baby’s well-being. You may not be able to function and may be overwhelmed by caring for your baby. You may experience changes in appetite that lead to weight loss or gain. You may also lose interest in everything, including your baby, and feel guilty or worthless as a result. If you suffer postpartum depression, treatments (including medications and psychotherapy) can make a big difference for both you and your baby.
Getting HelpAsking for help may seem like the hardest task in the world, especially if you feel exhausted and hopeless. Yet that’s just what you need to do if you have symptoms of depression. Remember, this disease often makes people feel bad, or guilty, about feeling bad! If you feel lost or stuck, or are concerned about a feeling, thought, behavior, or situation, seek help. I tell my patients to call and ask to speak with a nurse, or request a visit for a bladder or yeast infection. I am not encouraging misleading behavior, but I don’t want my patients to feel that they have to discuss this very personal problem with the first person who answers the phone in my office. The most important point is that the woman seeks help, not that she tell my front desk a white lie.
Together, you and your doctor or therapist can decide on a treatment plan to alleviate your distress. As with other types of depression, a combination of psychotherapy and medication is most helpful. The most commonly prescribed antidepressants are in the group known as selective serotonin reuptake inhibitors (SSRIs). They include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil) and citalopram (Celexa). The effects of each medication on the developing fetus may vary; talk with your care provider about the risks and benefits of any drug in pregnancy. If you are breastfeeding, an important concern is the possibility of passing medication to the newborn. However, most antidepressants are unlikely to have much effect on the baby because only small amounts get into breast milk. The best approach is to discuss the choices with your doctors to assess the risks and the benefits in your situation.
In addition, the following practical suggestions may help you navigate safely through this difficult time:
· Ask a friend or family member to accompany you to your first appointment to help describe your problem, assist you in getting treatment, or simply offer support.
· Take medications as directed. Don’t skip pills or change doses without consulting your doctor. Also, report any side effects right away, and if necessary, talk to your doctor about adjusting your treatment plan.
· Set realistic goals for yourself. Try not to take on more than you can handle.
· Join in activities, and try not to isolate yourself from others. Depending on your personal preferences, attending religious services, having a meal with an understanding friend, or going to a movie, ball game, or concert may help lift your mood.
· 
Try to exercise regularly or take a daily walk.
· Hold off on making big decisions — for example about moving or changing jobs— until your depression has eased or is under control.
· Friends and family often want to help. Let them.
Most mothers with postpartum depression recover completely. This is especially true if the illness is diagnosed and treated early. About 50% of women who recover from postpartum depression develop the illness again after future pregnancies. To decrease this risk, some doctors suggest that women with a history of postpartum depression should start antidepressants immediately after the baby is delivered, before they have a chance to sink into depression.
Final Thoughts
As a reader, you have probably figured out that I care deeply about this issue. The idea of feeling depressed during or after a pregnancy runs against our social myth of pregnancy being an ideal time in one’s life. I hope it is a wonderful experience, but I think it is equally important to be realistic. Motherhood is not always instinctive, all babies are not easy, and no one can be a perfect mother. As I tell my patients, my goal is a healthy mother-baby unit. There are many, many paths to get to that end goal, and each unique path can be right for a woman and her child.
Kristen Eckler, M.D., is an Instructor of Obstetrics, Gynecology, and Reproductive Biology at Harvard Medical School, and an Assistant Professor of Obstetrics, Gynecology, and Reproductive Biology at Massachusetts General Hospital.
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Comments: 17
so many woman have to be told over and over again that no one is a perfect mother, wife or spouse, we do the best we can with what we have and learn the skills we need to learn to improve but perfection is an elusive dream
When I worked as a family assistant in mental health, my clients who made the most improvement in the least amount of time are the ones who chose to change from being isolated and sedentary. As they begin moving and connecting, the changes in their appearance to outsiders was dramatic.
It is easy to become isolated during the course of pregnancy and after giving birth. Some women who worked and enjoyed it are suddenly cut off from daily community connections. Most humans are pretty social, and this can be traumatic on rather a subconscious level. It is easy to blame yourself if you don't understand that you may be going through a sort of biochemical withdrawal.
Figuring out how to be involved with others who are facing the same issues or who have come through them is a challenge if you feel your resources are limited, but it is worth the effort.
If you are on gather, you can try to connect with someone here.
If the power is out, and your electronics don't work, you can at least think of your favorite people. Our mental health system isn't a fast-response system in most places, unfortunately. You may have no choice but to draw on your own resources for a time.
Anticipating tough feelings and deciding ahead of time what you are going to do about them is a good strategy.
Establishing an exercise routine before pregnancy that you will be able to maintain even during pregnancy can be helpful. Even if you are told not to exercise, you can picture exercise in your head, and if it gave you pleasure, you can do virtual exercise.
I had a client who did an addictive amount of vigorous exercise before she became pregnant. She stopped exercise after delivering and became almost intractably depressed, which is why my agency was called in. All of the usual medical strategies had been tried, and they were not working.
Exercise is what pulled her out, but horrific suffering went on until we got it going. It is good to understand that exercise can trigger many feel-good chemicals. This is one of the reasons it is addictive.
Athletes who get injured are at grave risk for depression. More and more trainers are aware of this and warn their athletes to be on guard for it. Trainers can ask the people they care for to tell someone as soon as symptoms appear. As long as the person can breathe on his or her own, there are non-pharmaceutical interventions that can be worked with if medical mechanisms are not quickly obtainable.
A chi kung instructor in Portland pointed out in a class that visualizing exercise may help some people who are physically unable to move.
My pre-marital exam, in 1977, was by Dr. Bradley. I think the name of his book was Husband-Coached Childbirth. He made me take a glucose-tolerance test (yech!). He told me I was hypoglycemic and should therefore limit myself to two children. At the time, I was crestfallen. (After I had my two boys, I realized he was right, for more reasons than just my blood sugar.)
Some times romantic notions of your capabilities have to smack up against reality. It is good to keep funny books, music, video, and people around for just such an eventuality, even if they have to be virtual under emergency conditions.
I have suffered many losses in the past ten years. Silver-lining-detection exercises are ones I seem to need to practice daily.
Anybody have some good silver-lining stories to add?
This is a valuable thread. Thanks for posting.
m
KF Oakland, CA
Behavioral Health Specialist
Many thanks for your comments and feedback. As always, some extremely important points were raised that deserve further discussion.
First, there really is no excuse for a health care provider not returning phone calls. However, a reality of today's chaotic health care environment is that persistence is often required. If your call is not answered, then call back.
If a practice consistently doe not respond to calls, then I suggest you seek another practice.
Next, I greatly appreciate the comments of Mary S and KF, which highlight other options for treating low mood and depression such as exercise and behavioral therapy. My apology for not more specifically discussing non-medical treatments, which are just as important as drug therapy. The lack of attention was not an intentional oversight; rather, most of my patients want information specifically regarding medication risk. However, both exercise and behavior therapy are important tools in treating mood disorders. Thanks again for bringing these important modalities to the discussion.
Be well,
Kristen Eckler MD
Due to that fact and some other factors, Denmark has a very high suicide rate. Those very same principles drive our social-psychiatric system, and it is gravely flawed. I personally know several who have died due to that, so in reality my anger could be greater than KP's, though it isn't, since I perhaps see a larger picture. Does that make sense to you?
Agitated depression is a dangerous mood state, even if you only look at how much it increases accident risk. Depending on the person, medications can increase the agitation. Exercise can be very helpful for persons with agitated depression because it channels the energy. Water exercise can be especially good, because moving through water takes more energy than moving through air, the risk of falling is less, and water presses the capillaries and helps with venous return. Most people have lower blood pressure and lower heart rates in the water (an exception might be for someone who is afraid of water).
Other forms of exercise may be helpful if water is not a choice. Finding movements that feel good is the challenge, because especially in the beginning, one is more likely to do movements that feel good and that have a sense of accomplishment attached to them. I have found that arm movements in the mirror, where I can see the muscles tighten, are good. I have to be on guard against swelling in one arm where lymph nodes have been removed. So I know I am doing something good for myself when I watch the muscles work in that arm.
Coaches and personal trainers may palpate (touch) a muscle to show a client where the work goes on in a particular movement. Individuals can do this for themselves also. The next time you get up from a chair, if no one is looking, put your thumbs on the front of your thighs, and your fingers on the back of your thighs, and feel the work. Think of how much money you saved by doing it yourself.
I could not take a medication in the selective-seratonin-reuptake-inhibitor class even when it was prescribed against nausea after chemotherapy because it triggered severe headaches. Some people can take them. It is a very individual decision.
Temple Grandin, a person who identifies herself as having autism, takes medications, but she is very careful to log the effects and to work with prescribers who are supportive of her proactive and scientific ways of figuring out what works for her. I recommend her books. She came to Portland a few years ago and sold out a venue that held 1,000 people.
The more people hear remarkable stories such as that of Temple Grandin, the more similar remarkable stories there will be. I first heard about her in the work of Oliver Sacks, who wrote the book that became the movie, Awakenings.
Thanks for this thread. I have appreciated reading and responding.
Mary