Often seen as a postpartum problem, depression should be treated during pregnancy by Judith A. Weinstein and Susan B. Cahn
illustration by Madeleine Avirov
When Beth, a 36-year-old communications specialist, found she was pregnant, she started prenatal care visits and began to share the news with her family and friends. But instead of feeling elated, she started to feel depressed.
"Once the ‘apparatus of pregnancy' took over," she says, "it started to overwhelm me. Then I started to feel fear. Then I had a reaction to the fear. I thought to myself, ‘I shouldn't be feeling fear, I should be feeling unbridled joy!' "
Her ambivalence about the pregnancy, coupled with the sheer physical exhaustion of her first trimester, left her feeling anxious and isolated. She did not anticipate these feelings as part of her pregnancy and decided to seek treatment for depression.
Headlines of a few desperate women who took their lives due to postpartum depression have put the issue in the minds of the public. But research now shows that postpartum depression is probably prepartum depression beginning long before the child's birth.
Each day tens of thousands of pregnant women in Chicago see obstetricians, midwives or nurses for routine prenatal care. At each visit they get on scales, don blood pressure cuffs and give urine samples to screen for diseases and disorders during pregnancy. Despite all the attention to physical health during pregnancy, few practitioners pay attention to a woman's mental health during pregnancy. That means women are suffering needlessly since depression is one of the most common treatable diseases worldwide.
But people don't understand mental illness and it is further complicated by the social stigma attached to depression. The women interviewed for this story didn't want their real names used because of it. A few have never even told their families about their episode of depression during pregnancy.
It's all still very confusing to patients and doctors. At what point should a pregnant woman seek mental health care? Feeling overwhelmed and anxious or experiencing changes in appetite and sleep are all symptoms of depression. Yet, they're also normal symptoms of pregnancy. Both pregnancy experiences and symptoms of depression vary among women.
Janet, the 20-something mother of a 2-year-old, had a high-risk pregnancy with her second child. The stress of the difficult pregnancy was overwhelming. "I would wake up and cry, thinking, ‘How am I going to get through this day?' I felt the onus was on me not to mess up, although plenty of times I just wished I would miscarry so that it was over. I'm ashamed to say that now, but that's how I felt."
Most women and their families are aware of postpartum depression. In the last three years, there have been at least four well-publicized suicides of women suffering from postpartum psychosis. Andrea Campanari, 33, of Evanston, slit her wrists in a bagel shop bathroom a week after giving birth to her son. In 2001, three Chicago women committed suicide within several weeks of one another: Melanie Stokes, mother of a 5-month-old daughter; Jennifer Mudd Houghtaling, mother of a 5-month-old son, and Aracely Erives, who drowned herself less than a week after delivering quadruplets.
These deaths sent wake-up calls about the effects of untreated depression in pregnant women and new mothers. Tragic as these events are, the underlying cause is relatively rare-postpartum psychosis, when a mother loses touch with reality (one in 1,000 women) and should be considered a true medical emergency.
Mild depression is common Most women-about 80 percent-experience a form of mild depression, thought of as baby blues or mood swings, within 48-72 hours of delivery. But 10 to 21 percent of women have clinically significant postpartum depression-a condition many believed emerged in the first few months after delivery. We are just beginning to understand that it is more likely to start during pregnancy.
"Postpartum depression is very often simply a continuation of prepartum depression," says Dr. Nada Stotland, psychiatry professor at Rush Medical College in Chicago. "The symptoms are the same as those of depression at any other time: changes in appetite, sleep, mood, energy, concentration, inability to enjoy things."
"Taking steps during pregnancy to treat depression puts you in a better position to deal with postpartum episodes," says Susan Feingold, a clinical psychologist whose practice focuses on women's health issues. She estimates as many as 50 percent of cases of postpartum depression are a continuation of prenatal depression.
Unplanned, unwanted or difficult pregnancies or even the stress of pregnancy may trigger the onset of depression-depending on the woman. For women undergoing fertility treatments, the strain sets in months or even years before they actually conceive. According to Feingold, "These women are at higher risk [for depression] because of the ups and downs of the fertility treatment cycle and the increased hormones used to promote fertility."
A woman's health issue Depression is one of the greatest diseases burdening developed countries, second only to heart disease, according to the World Health Organization. In the United States, it is the second most common diagnosis in the adult primary health care setting according to the Agency for Healthcare Research and Quality, and the leading cause of disability. A federal study in 2003 found about 7 percent of Americans suffer from depression or mood disorders each year. Sixteen percent have experienced a major depressive episode in their lifetime.
Depression is a particular problem for women. One in five women will experience a major depressive episode in their lifetime, twice the rate of men. Depression hits women most often between ages 18 and 44, the so-called reproductive years. Depression rates do not appear to increase during pregnancy, nor do they decrease either.
Sadly, there is no inherent protection from depression in pregnancy. In some women, the pregnancy itself may trigger an episode. The Illinois Department of Public Health reports 50,000 live births in Chicago annually, and that means as many as 10,000 pregnant women may have experienced depression during a year.
"Mood disorders are common in women of child-bearing years, and it has been estimated that 15.6 percent of women meet criteria for major depression during the third trimester of pregnancy," according to a report released last month from the federal National Toxicology Program.
It's important to remember, though, that depression is a treatable and curable disease. While pregnancy may present certain challenges to treatments-especially when it comes to antidepressant medications-it is also an opportune time to diagnose and treat the illness because pregnant women are in regular care.
Moreover, diagnosis and treatment of prenatal depression may prevent or diminish postpartum depression.
Diagnosis of depression does not require lengthy or expensive tests. The U.S. Preventive Services Task Force says health care providers need ask only two simple questions: "Over the last two weeks have you ever felt down, depressed, or hopeless?" And "Over the last two weeks, have you felt little interest or pleasure in doing things?" If a patient answers, "yes," it is an indication there needs to be more in-depth diagnosis or referral.
Misdiagnosed or dismissed? Regrettably, many providers do not ask these simple questions, and many women may not mention that they are sad or have decreased pleasure in activities or physical symptoms such as weight loss or insomnia. Sometimes women are not able to distinguish that these may be symptoms separate from pregnancy.
Why aren't maternity care providers more proactive in identifying depression in their patients? According to Stotland, there are a number of reasons, including tradition, the stigma of psychiatric disorders, limited time with a patient and the lack of resources for referral and treatment if depression is diagnosed.
A woman should feel comfortable discussing her mental health with her provider, as much to rule out a diagnosis of depression as to determine whether further treatment is necessary, says Carol Hirschfield, a certified nurse-midwife. She continues: "Even the most well-planned, well-timed, well-thought-out pregnancy can be associated with some ambivalence. This ambivalence can cause a woman to feel guilt, especially if she has been trying for a long time to get pregnant. Recognizing that these feelings are normal is so important, as is good communication with one's spouse or partner."
Stotland agrees and tells women not to ignore their symptoms. "If patients are dismissed by their health care professionals for any reason, they should protest to the clinician and to the clinician's superior or the hospital, and if they don't get satisfaction, switch health care professionals, if possible," she says
Depression screening is becoming more common, especially in hospital-based obstetrical programs. Maria, a health care consultant, was in psychotherapy for depression in the mid-1990s, while her daughter was a toddler. She later realized that her depression had started during her pregnancy. Now, eight years later, pregnant with her second child, she was screened prenatally for depression at the same hospital-based practice in North Carolina where she delivered her first child.
Hirschfield confirms that she and her colleagues in the obstetrician/midwife group at Northwestern Memorial Hospital assess new patients for depression and other mental health disorders. They are also on the alert for mood changes with women who have been their patients for years.
Treatment available The good news for pregnant women today is that there is better awareness about depression among obstetric providers and there are also better treatment options. Moreover, our knowledge of both drug and "talk" therapy has increased tremendously. Most antidepressants are "Category B" drugs, meaning they have not shown risk to fetuses in animal studies, although controlled studies in pregnant women have not been conducted.
Women concerned about medications will be heartened to know that many studies have shown talk therapy to be just as effective as drugs in some women. Feingold says that while individual plans vary, she has treated women who needed as few as two months of therapy. For those who cannot afford individual counseling, community support groups, usually postpartum, are an important option.
Double depression Talia, a stay-at-home mother of a kindergartner, says she has been depressed for as long as she can remember, certainly her entire adult life. She was first diagnosed with dysthymia, a chronic form of depression with a longer duration and fewer symptoms than major depressive disorder.
When people with dysthymia experience an episode of major depressive disorder, this is known as a "double depression." In her mid-20s, Talia started taking the antidepressant Prozac. She has also been in some form of individual psychotherapy or group therapy ever since.
After getting married and moving to Chicago, Talia asked her doctor about stopping her medication. "I wasn't planning on a pregnancy right away, I just wanted to get off of the drugs," she says.
When she and her husband decided to start a family, Talia got pregnant quickly. During her pregnancy, she didn't feel depressed.
"I was a bit more emotional, crying more easily, and everyone was mother-henning me." Pregnancy, she says, made her feel calm and "blessed out." But after her son's birth, while still in the hospital, her mood plummeted, and she returned to her long-term depression.
Like other women with a history of depression who experience a respite from the disease during pregnancy, Talia's "new" postpartum depression may have been a recurrence of chronic depression.
But it is clear that her choice to remain in psychotherapy throughout her pregnancy helped in an early diagnosis and possibly to diminish the severity of her episode.
Resources • The Chicago Department of Public Health operates 16 mental health clinics with services on a sliding fee scale. (312) 747-0036.
• Northwestern Memorial Hospital "Transitions to Motherhood" classes and New Moms' Support Group, facilitated by a clinical psychologist. $120 for six weeks. Call Kim Kocur at at (312) 926-7317 or visit www.nmh.org/classes/supp_women.html.
• Family Network in Highland Park, a social service agency. Sponsors a support group for postpartum women. (847) 433-0377.
• Evanston Northwestern Healthcare Mom's Line is staffed by licensed professionals, providing referrals to counselors in private practice who will see clients within 48 hours. (866) 364-6667
• Marriage and Family Therapy Clinic at Purdue University at Calumet in Hammond, Ind., has a sliding-fee scale. (219) 989-2027.
• The Pregnancy and Postpartum Mood and Anxiety Disorder Program at Alexian Brothers offers free services Elk Grove Village, (847) 981-3594, and Hoffman Estates, (847) 755-3220.
• Parenthesis Parent Child Center serves parents and children in Oak Park and River Forest with in-home parenting support and teen programs. Contact Melissa Novak, (708) 848-2227.
* WEB EXTRAS
Postpartum resources Books, facts, symptoms and Web sites to help you through it all For women experiencing depression during pregnancy there are many options for diagnosis and treatment. But, as with any health care issue, it can only help to be an informed advocate for oneself. The following resource guide is provided to help women in helping themselves as well as the families they nurture.
Symptoms of depression These are a list of possible symptoms of depression from the National Mental Health Association's Web site, www.nmha.org. • A persistent sad, anxious or "empty" mood • Sleeping too little or sleeping too much • Reduced appetite and weight loss, or increased appetite and weight gain • Loss of interest or pleasure in activities once enjoyed • Restlessness or irritability • Persistent physical symptoms that don't respond to treatment [such as headaches, chronic pain, or constipation and other digestive disorders] • Difficulty concentrating, remembering, or making decisions • Fatigue or loss of energy • Feeling guilty, hopeless or worthless • Thoughts of death or suicide Facts about depression Major depressive disorder (MDD) is the leading cause of disability in developed countries such as the United States, according to the Worth Health Organization; • 16 percent of Americans suffer from MDD • A major depressive episode may last 9 months, if untreated • Depression will recur in 80-90 percent of individuals in the first year, if untreated; • Women are twice as likely as men to suffer from MDD; • Depression rates do not appear to differ between pregnant and non-pregnant women; • Depression is a highly treatable disease, and a range of treatments are available for pregnant and breastfeeding women. Books When Words Are Not Enough: The Women's Prescription for Depression and Anxiety, by Valerie Davis Raskin, MD. Broadway Books, 1997. Beyond the Blues: A Guide to Understanding and Treating Prenatal and Postpartum Depression, by Shoshana S. Bennett. Moodswings Press, 2003.
Web sites Depression After Delivery www.depressionafterdelivery.com
Pregnancy and Depression www.pregnancyanddepression.com
Judith Weinstein has a master's degree in public health and is a researcher, educator and the amazed mother of 9-year-old Abigail and 5-year-old identical twins David and Ethan. Susan B. Cahn has a master's in health sciences, is a health care consultant and proud mother of 5½-year-old Allie and 5-month-old Ascher.
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