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Pre-birth blues: Depression doesnít always wait until the baby comes

August 24, 2015


Kate Moser waited until the night before her due date to set up the nursery.

Dark emotions had persisted throughout her pregnancy, despite the 32-year-oldís efforts to be positive. Thus, the eve of her 2014 due date found Moser and her husband piecing together the crib.

Moser did not have a glowing pregnancy. After two wrenching miscarriages, the Chicago teacher felt fraught with anxiety and fear that she tried to suppress. Strangers commenting on her growing belly left her feeling wilted or incensed. Driving to a doctorís appointment seemed impossible.

"I felt like I was walking a plank every time," she said.

Moser is one of many women who suffer depression and anxiety while pregnant. The American College of Obstetricians and Gynecologists estimates one in seven women experience depression during pregnancy or within 12 months of delivery.

"Itís very, very common," said Dr. Marcela Almeida, director of the Womenís Mental Health service at the University of Illinois at Chicago, which treats hundreds of women from multiple states.

But despite growing awareness of postpartum depression or "the baby blues," anxiety and depression during pregnancy remain underreported, with no standard screening procedures in place, experts say.

And yet, "itís the most psychologically vulnerable time in a womanís whole life," said Kellie Wicklund, a Philadelphia psychotherapist specializing in reproductive mental health.

Hormones, stress, infertility, previous experiences with depression or anxiety ó all act as triggers, experts said, with isolation often exacerbating them. Facebook CEO Mark Zuckerberg shared recently that he and his wife, Priscilla, are expecting a baby girl after three miscarriages. Their pregnancy journey was "a lonely experience," he said, adding that he hopes sharing their struggle will foster openness.

Behind smiling belly shots floating across social media, many say they feel pressure not to be negative about their pregnancy.

Although many women report a range of mental health issues while pregnant ó from suicidal thoughts to poisonous, persistent unhappiness ó fewer than 20 percent of women diagnosed during postpartum had self-reported symptoms, according to the American College of Obstetricians and Gynecologists.

"Youíre supposed to be enthralled with being pregnant and excited and have all positive feelings about it, and a lot of women are just ridden with anxiety," said clinical psychologist Dr. Gina Hassan, who offers therapy for pregnant women at her California practice. "Itís very hard to speak openly about that with others."

Last week, the U.S. Preventive Services Task Force recommended that pregnant women be screened for depression.

The U.S. Centers for Disease Control and Preventionís most recent relevant statistics, from the 2005-2009 National Survey on Drug Use and Health, show about 8 percent of pregnant women ages 18 to 44 had reported depression during the past year.

Other studies paint an even more troubling portrait. Dr. De-Kun Li, a senior research scientist studying prenatal depression at the Kaiser Permanente Division of Research, estimates that as many as 20 percent may experience depression symptoms during pregnancy. The reality is likely even higher, he cautioned.

In interviews, women recounted a range of struggles.

One 29-year-old woman battled toxic thoughts and depression, as strangers constantly asked her about her post-pregnancy plans. "Each comment would make me spiral further," she said.

A 29-year-old mom of a toddler son is delaying having a second child after her first pregnancy emotionally shattered her and her husband. Ravaged with twice-daily sickness and what she now realizes was depression, neither of them was sure how to find help.

Another woman, 31, said that, during her last pregnancy, she researched how long it would take to bleed to death without hurting the baby. For months, scared her older two children would be taken away, she told no one ó not even her husband, who is a nurse.

For Moser, it was hard to articulate her loss of happiness.

"You lose that joy that a lot of women and families experience during a first pregnancy, and strangers donít realize that," she said. "They just see you being pregnant and feel like itís acceptable to rub your belly and talk to you about the baby."

Many see awaiting a child as magical and merry, Hassan said, and that cultural expectation contributes to feelings of guilt and shame when hopelessness creeps in instead.

An unexpected positive pregnancy test can spur stressors, like planning for a new phase of life, perhaps marriage or moving ó those alone being enormous life changes. And even a pregnancy both orchestrated and welcomed can deal a blow.

"Women are caught off guard," Hassan said. "They planned the pregnancy and anticipated it, and itís not what they expected."

Hassan tailored her practice toward infertility and pregnancy after seeing her sister and close friends in distress and recognizing a dearth of support.

"They come in afraid and with a lot of shame," she said. "And they feel very isolated."

Adding to the isolation can be friends raving about their pregnancies. Meanwhile, oneís own baby shower might require a plastered smile.

Also, Hassan said, women are giving birth later in life, when itís intended to slip nicely into a cultivated path.

"Often weíve carefully crafted our career and our relationship and our lives, and then we get pregnant, and itís the first huge experience of not being able to be in control," she said.

A "PERFECT STORM": Experts say the list of issues compounding stress in pregnancy is long.

Physical ailments take a mental toll. Fears of delivery cloud moods. Working during pregnancy restricts time for rest, all while women are forging a new identity as mothers. Worries about the babyís health can spiral. Infertility or previous losses add layers of anxiety. Studies also show exposure to racism or poverty can wreak mental distress.

Wicklund called everything women go through during those nine months a "perfect storm."

"Itís a surprise when people donít have a mood impact or an anxiety impact," she said. "Thatís more surprising."

SIGNS: As a birth doula, Eleanor Turner looks out for small signals: disinterest in a baby shower, perhaps, or a dismissive attitude about the babyís progress.

Maybe a client casually says, "I donít really know that Iím bonding," as an example, said Turner, who owns Lemonade Babies in Wisconsin, which offers services before and after pregnancy. Or, "I havenít really felt the baby move, so I donít really even know thereís anything in there."

Almeida said signs of depression, which experts caution can be mistaken for typical pregnancy changes, include less energy, changes in sleep or appetite, and feelings of guilt, helplessness and hopelessness.

Strong negative emotions during pregnancy can domino, spiraling into fears of motherhood.

"It does bring up sort of self-doubt, ĎMaybe I wasnít meant to be a mother, maybe I shouldnít be a mother, maybe this is a sign,í" Hassan said. "As opposed to, ĎThis is how my body is responding and something Iím going through, and itís not necessarily permanent.í"

FINDING HELP: The first step toward help, Almeida said, is openness about feeling down.

Regular screening is needed, Almeida said. The Womenís Mental Health service encourages a collaborative approach, involving nurses, social workers and psychiatrists.

But not every doctor brings up mental health in a prenatal exam. There is no standard question or protocol to screen for depression during pregnancy.

"Ideally that should be part of the routine prenatal care," Almeida said. "In clinical practice, it really varies a lot."

In a May report, the American College of Obstetricians and Gynecologists advised that women be gauged for depression at least once. It suggested a standard screening tool and readiness to refer to a therapist.

"The impact of untreated perinatal depression can have a devastating effect on families," President Mark S. DeFrancesco said in a statement.

After birth, doctors typically use the Edinburgh Postnatal Depression Scale to gauge mothersí mental health. About a five-minute questionnaire, it asks about the past week with statements like "I have felt scared or panicky" or "I have been so unhappy that I have been crying."

A similar tool would be helpful during pregnancy, many experts say.

The American Psychological Association has blasted the lack of screening. In a 2014 article, it called pregnancy-related depression the most common serious condition affecting pregnant women. The authors suggested adding two depression-screening questions to check-in forms.

Almeida urged women to feel comfortable confiding in their physician. Be honest, she said: "That way we would be able to help them."

Treatment is very personalized, Almeida added. Therapy and medication both come up in conversations with patients.

Whether women should take medication during pregnancy is a controversial conversation. Almeida said every person is unique ó medication might be considered useful for some; others might benefit from seeing a counselor. Some doctors might be comfortable treating them through regular check-ins, Almeida said.

Moser, who now has a bubbly 9-month-old daughter, said that slowing down, allowing space for emotions and joining a support group helped.

"A lot of people feel guilty for having those feelings, which of course compounds the feeling, because they feel like they should just be just overjoyed," she said. "Having people who really understood and were not at all judgmental of what I was going through, internally, it helped tremendously."

Partners, friends and family can play a huge supportive role, doctors and therapists said. One thing to avoid? Focusing only on the baby, or saying things like, "Once the babyís here, youíll feel differently."

"Because for some women, that doesnít happen," Turner said.

Partners, who experts say often are first to spot symptoms, should proactively ask women how theyíre feeling and provide patience and a team-oriented philosophy.

"That can really help the mother feel like sheís not alone," Turner said.

Indeed, women are not alone. Talking to someone, whether a partner or medical care provider, is an important first step, experts said.

"The more itís kept inside, the darker it becomes," Hassan said.

On an emotional level, Turner strives to help clients understand they are not alone or at fault. Emotions ó positive or negative ó can all form part of the experience, she said.

"Itís OK to own those feelings," she said. "Theyíre not doing anything wrong."

RESOURCES:

The federal Health Resources and Services Administration provides this Maternal and Child Health resource for depression during and after pregnancy: http://mchb.hrsa.gov/pregnancyandbeyond/depression/index.html

Almeida directs patients to this list of support resources around the country: http://womensmentalhealth.org/resource/patient-support-services

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