Pregnancy & Birth
Depression and Other Mental Health Challenges During Pregnancy
Despite the stereotype that all pregnant women are glowing, for some women pregnancy is a difficult time. Symptoms of depression include loss of pleasure in activities that you used to enjoy; persistent feelings of worthlessness, sadness, or hopelessness; prolonged periods of appetite change or fatigue; uncharacteristic tearfulness; or suicidal thoughts. It is possible to be depressed without actually having feelings of sadness. Though depression can affect any pregnant woman, it is more common in women who have experienced depression in the past.
It can sometimes be hard to differentiate between feelings of sadness that are part of the normal range of response to challenging life experiences and serious depression that calls for more than basic support and help with problem solving. The medical definition of depression typically ignores the cause(s) of a woman’s distress, and thus often fails to address specific issues such as poverty, discrimination, sexual assault, abusive relationships, or the end of a relationship that contribute to feelings of sadness, poor self-image, and despair.
Too often women experiencing reasonable responses to difficult life situations are treated by health care professionals with mood-altering medications that can have unwanted side effects. These medications—whose popularity is fueled by simplistic and unrealistically optimistic advertising—are often prescribed before women are offered more holistic approaches that have been demonstrated to be equally or more effective. However, when social support systems are not readily available or talk therapy is not helpful, some women do find that medications can provide relief, especially by helping them return to normal function in the short term.
Currently, in North America, pregnancy is treated as though it is an at-risk situation for depression, and routine prenatal care includes screening for depression. Nonetheless, evidence shows that pregnant women experience no more depression than women who are not pregnant. According to one large systematic review, about one in every thirteen pregnant women experiences some depression.17 In a survey of U.S. women of reproductive age, there was not a significant difference in rates of depression between pregnant and nonpregnant women, and the trend was actually toward pregnant women experiencing less depression.18
Why is there potential harm with screening? Screening large, generally healthy groups of people inevitably produces false positives that may result in healthy people being labeled as having a mental health disorder and exposing them to the unnecessary risks of treatment. Furthermore, although many believe that detection and treatment of depression in pregnancy have been shown to prevent depression after birth, there is little scientific evidence to support this view.
Symptoms of serious depression may develop in the context of challenging life circumstances, or they may arise with no apparent cause.
|Ever since my eighteenth week of this pregnancy, I have been feeling depressed. I feel flat/unhappy all the time, I cry a lot, I can’t sleep, I can’t concentrate, I’m impatient with everyone, and not even playing with my toddler makes me happy anymore. This is a much-wanted pregnancy, and there is nothing going on in my life that should be making me so unhappy.19 |
If you are pregnant and experiencing feelings of mild to moderate sadness, the first things to do are to try to get enough sleep and exercise, eat well, and reach out to friends, family, religious counselors, and/or specialized support groups for practical and emotional support. If these strategies do not ease the depression, seek help from a health professional, such as your primary care provider or ob‑gyn, or a psychotherapist, social worker, or psychologist with experience treating depression during pregnancy. Depression is treatable, and a good therapist can provide support and guidance as well as help assess whether additional treatment may be helpful. If you have concerns about hurting yourself or others, or an acute sense of hopelessness or inability to function, seek medical attention immediately.
Antidepressants are commonly prescribed during pregnancy. Although these medications are widely believed to be very effective, a recent review of all the clinical trials submitted to the FDA—including negative studies pharmaceutical companies chose not to publish—found that antidepressant medications are only slightly more effective than placebos.20* For people experiencing mild to moderate depression, they were no more effective than a placebo. Among people who were suffering from major depression, only one of ten people treated with antidepressant medication significantly improved as a result of taking the medication. Among people whose depression was categorized as “very severe,” one out of four responded to antidepressant medication.
Furthermore, antidepressants have not been shown to be more effective for mild to moderate depression than nondrug options such as psychotherapy, cognitive behavioral therapy, and exercise. The clinical trial evidence strongly supports a model of symptomatic treatment focusing on life situation, rather than a model of an imbalance in brain chemistry that is “fixed” by antidepressant medication. Most depression is episodic, generally resolving (even without treatment) in about four to six months.
Although some clinicians believe that antidepressants are more effective than shown in clinical trials, the only scientifically valid way to determine whether and by what margin medication is superior to treatment with a placebo is from the results of randomized, double-blind, controlled trials.
In addition to the question of effectiveness, there is some concern about the possible risks of taking antidepressants during pregnancy. For example, can they cause birth impairments? Do they increase the risk of miscarriage? Several studies suggest that there is an increased risk of heart defects in infants whose mothers take antidepressant medications, especially paroxetine (Paxil and generic equivalents),21† and some evidence that women taking certain antidepressant medications have an increased risk of miscarriage.
There have also been reports of some harmful effects on infants of women who took antidepressants in the last trimester of pregnancy, including effects such as jitteriness, crying, and feeding problems that may be withdrawal effects, and very rarely, a serious disorder called persistent pulmonary hypertension.22 There has been controversy surrounding all of these risks and the medical evidence is being hotly contested in legal cases. More research is needed to answer questions about potential risks, including risks that may be due to underlying differences (unrelated to drug use) between women who do and don’t take antidepressants.
For women who become pregnant while taking antidepressant medication, these concerns must be weighed against the risk that stopping antidepressant medication during pregnancy will lead to worsening of depression or the symp- toms of drug withdrawal. One study showed a high rate of depression relapse when pregnant women were taken off their antidepressant medication, but the study did not gradually taper the dose of medication and failed to distinguish between symptoms of drug withdrawal and recurrence of depression.23
Depression in pregnant women is associated with low weight gain, alcohol and substance abuse, and sexually transmitted infections, all of which can harm mothers and babies. Although there is no evidence that taking medications will prevent any of these problems, women with severe depression clearly need professional help.
In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) recommends the use of older and less expensive tricyclic antidepressants rather than newer drugs such as Prozac, Paxil, and Zoloft because of the longer experience with their use and because of concerns that the newer antidepressants may be less safe overall during pregnancy.
Pregnant women who are struggling with other mental health problems, such as bipolar disorder, anxiety, or post-traumatic stress disorder may be offered medications other than antidepressants. If medication is recommended, make sure that you are fully informed about its benefits and adverse effects, as well as the full range of alternatives—both drug and non-drug. Also, check the FDA’s assessment of the safety of each medication for use in pregnancy. (This information is included in the package insert of each prescription medication, which is available from your pharmacy.) You and your health care providers can also get free information on the possible risks of medication on your pregnancy from the Organization of Teratology Information Specialists (otispregnancy.org).#
Excerpted from the 2011 edition of Our Bodies, Ourselves. © 2011, Boston Women's Health Book Collective.
* Estimates of higher efficacy are possible when one selects a subset of clinical trials that omits studies showing less efficacy or when an analysis puts a positive spin on negative results. It is also true that many studies show a considerable response rate to a placebo. Moreover, most depression episodes are temporary and resolve on their own, and in many cases it is hard to distinguish between the effects of drugs and those of other forms of social support and care.
† The FDA has classified paroxetine as class “D” in pregnancy. This means that the FDA has determined good evidence of human fetal risk and thus recommends “do not use” during pregnancy. The other SSRIs are classified as “C,” indicating that there is only animal evidence and/or lack of human studies. Therefore, the FDA recommends their use with caution. Drugs classified as “A” or “B” are generally considered appropriate for use in pregnancy; “D” and especially “X” drugs should be avoided if possible.
#Teratology is the study of the causes and biological processes leading to abnormal fetal development and birth impairments.
17. B. N. Gaynes et al., “Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes,” February 2005, http://archive.ahrq.gov/clinic/tp/perideptp.htm. The full report is AHRQ Publication No. 05-EE006-2. This is a systematic review that reported a rate of 3 to 5 percent per trimester of pregnancy, with 7.5 percent of women experiencing an episode of major depression in pregnancy (i.e., depression that meets the criteria for a diagnosis).
18. O. Vesga-López et al., “Psychiatric Disorders in Pregnant and Postpartum Women in the United States,” Archives of General Psychiatry 65, no. 7 (2008): 805– 15. They found that 5.6 percent of pregnant women versus 8.1 percent of nonpregnant women met diagnostic criteria for depression (but the difference was not significant).
19. “Depression During & After Pregnancy,” December 2007, parents.berkeley.edu/advice/pregnancy/depres sion.html.
20. E. H. Turner et al., “Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy,” New England Journal of Medicine 358 (2008): 252–260; Irving Kirsch et al., “Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration,” PLoS Medicine, 5, no. 3 (2008); H. Edmund Pigott et al., “Efficacy and Effectiveness of Antidepressants: Current Status of Research,” Psychotherapy and Psychosomatics 79 (2010): 267–79.
21. S. Alwan et al., “Use of Selective Serotonin-Reuptake Inhibitors in Pregnancy and the Risk of Birth Defects, New England Journal of Medicine 356 (2007): 2684.
22. “Are Antidepressants Safe in Pregnancy? A Focus on SSRIs,” Therapeutics Letter 76 (January–February 2010), ti.ubc.ca/letter76.
23. L. S. Cohen et al., “Relapse of Major Depression During Pregnancy in Women Who Maintain or Discontinue Antidepressant Treatment,” Journal of the American Medical Association 295, no. 5 (February 1, 2006): 499–507. This study was the subject of a Wall Street Journal exposé (July 11, 2006), because among the thirteen study authors there were sixty undisclosed conflicts of interest. There were also serious methodological problems with this study: (1) the study was not blinded or randomized and failed to report on key health outcomes; (2) women were considered to have discontinued if they were off antidepressants for one week or more in pregnancy, even if they took antidepressants the rest of the time, and any “recurrence” that occurred was linked or classified as being among “discontinuers” even if a woman had been on antidepressants for months before and after the recurrence occurred; (3) there was no protocol for gradual withdrawal from antidepressants, probably leading to some abrupt discontinuations that would increase the severity of withdrawal reactions; (4) the authors did not mention withdrawal reactions and failed to report a single withdrawal reaction; however, the timing of depression recurrences suggests that many were withdrawal reactions; (5) women were warned that if they withdrew from antidepressants, their depression might recur; (6) reporting of trial results was grossly inadequate—no serious or nonserious adverse reactions reported,no quality of life reported, no infant health outcomes reported. A factor making the results even harder to interpret is that the women in the study were warned ahead of time that if they stopped their antidepressants their depression might recur, but they were not warned about the possibility of drug withdrawal effects. This is likely to have led to some misdiagnoses.
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