21 Oct When everything is not ok: Untreated Prenatal Depression and its Possible Complications
We used to believe that women were protected from mental health challenges during pregnancy. The idea was that the high levels of “feel good” hormones, such as Estrogen and Progesterone, provided women with that protection. However, in the last decade there has been cumulative evidence to suggest otherwise. In fact, recent surveys suggest that over 18% of pregnant women experience some depressive symptoms and over 10% of pregnant women develop a full blown Major Depressive Episode. The percentage is higher among women in disadvantaged populations (for a full review, see Davalos et al., 2012). The World Health Organization declared that depression was the leading cause of disease worldwide among women of childbearing age (WHO, 2001).
Risk factors include, but are not limited to
• An unplanned pregnancy
• Having no partner
• Distressed partner relationship
• Social isolation/lack of support
• Previous trauma, including birth trauma
• History of mental illness in the family
• History of mental illness in the pregnant woman
• low level of education
• young maternal age
• recent immigration
Depression is always devastating to the person experiencing it as well as the people close to them. Depression during pregnancy is especially disconcerting because of societal expectations that a pregnant woman should be happy and elated with the anticipation of becoming a mother. Moreover, there is now evidence that prenatal depression and anxiety may seriously affect the health of the fetus with possible life-long negative effects. In a comprehensive review of the literature, Davalos et al. (2012) summarized studies which looked at these effects. Negative effects ranged from premature birth, low birth weight, problems with fetal growth and compromised early brain processing resulting in a heightened stress response, to difficulties with emotional regulation in infancy, lack of empathy during the toddler/pre-school stage and psychopathology during adulthood.
Not treating depression and anxiety during pregnancy is NOT an option!
Yet another alarming statistic is the fact that over 50% of depressed and anxious pregnant women are undiagnosed by care providers and does not receive appropriate treatment. One of the reasons why so many women go under the radar, so to speak, is that many symptoms of depression and anxiety overlap with common complaints during pregnancy. For example, changes in appetite and sleep, irritability and mood swings and mild levels of anxiety are common among pregnant women. Another reason is that primary care physicians have very little time to spend with each patient.
To make sure a health care provider is able to detect mental health issues that may warrant intervention in a pregnant woman, a specific screening tool such as the Edinburgh Postnatal Depression Scale should be used, along with specific mood questions such as: “How has your mood been in the past couple of weeks?”
Below is a comparative table, which may help in differentiating between minor common complaints during pregnancy and significant uncommon symptoms during pregnancy, which may serve as a red flag.
|Common complaints & behaviors during pregnancy||Significant warning signs during pregnancy|
|• some irregularity of sleep, e.g., getting up to go to the bathroom and easily falling back to sleep|
• nausea and occasional vomiting (especially in the first trimester)
• seeking and following advice on nutrition, supplements and exercise to optimize health of mother and baby
• some mood swings, ups and downs, being more emotional than when not pregnant like crying for minor reasons
• some worry related to the stage of pregnancy (i.e., worrying about losing the pregnancy in the first trimester while worrying a about pain during labor and birth during the third trimester). The worry is not debilitating and does not disturb normal functioning or sleep
• feeling more tired than normal, especially during the first and third trimesters
• Nesting. Working to make sure everything is ready for the baby
• minor aches and pains
|• Severe sleep disturbances. Being unable to fall asleep for hours, middle of night waking and staying up for hours or early awakening
• Significant weight loss or gain above and beyond what’s common in specific pregnancy stage
• Obsessive thoughts and information seeking behaviors regarding nutrition, supplements, medical intervention during birth, etc.
• Mood is mostly down, depressed and at times hopeless. Rare if any “ups.” Being unable to stop crying spells that last hours.
• Excessive worry, anxious thoughts that won’t ease with reassurance, expressing overwhelming anxiety most of the time
• Tired all the time, being unable to go to work or function at home
• Social withdrawal
• Obsessive worry and nesting behavior gone out of control, e.g., investing weeks researching the best stroller or buying hundreds of items for the baby
• Paralyzing worry about labor and delivery accompanied with bleak predictions for the future or the outcome of pregnancy
• Feeling unwell without an identifiable physiological reason
Pregnant women who may be depressed should be referred to a mental health professional, such as a Registered Psychologist or a Psychiatrist as soon as possible.
Evidence-Based, non-pharmacological Treatments for pregnant women who struggle mentally
Please note: Whereas there are certain medication that may be prescribed to pregnant women who are experiencing mood disorders, I am focusing here on non-pharmacological treatments. There are several reasons for that. First, as a psychologist, I do not prescribe medication although I will work in collaboration with physicians who do. Second, many pregnant women do not wish to take medication in fear of harming their baby. Third, there are excellent non-pharmacological treatment options available, which do not have any side effects and cannot harm the baby. Hence, in my view, these should be the first go-to treatment option. If a pregnant woman is interested in medication or in cases where she is seriously ill and requires hospitalization and medication, non-pharmacological treatments can and should be provided in conjunction with medication.
The following is a brief description of the most evidence-supported psychotherapies and techniques for the treatment of depression and anxiety. Following a thorough assessment, a trained and experienced mental health professional would be able to educate a pregnant woman about her treatment options and, tailor the appropriate treatment, or combination of treatments, to the client.
Breathing and relaxation exercises – when pregnant women are depressed or anxious they usually take shallow and relatively quick breaths and their muscles are often tight. This type of breathing and muscle tightness not only do not help their situation, but are likely to make it worse. Breathing retraining and relaxation exercises, which help the whole body to relax, improve blood circulation and oxygen processing in the body and benefit body and mind.
Regular exercise – women who suffer from depression and/or anxiety are many times reluctant to engage in regular exercise. They are often too tired, lack the motivation or hopeless or uneducated about the benefits of exercise to both physical and mental health. Numerous studies have confirmed that regular exercise is as beneficial as anti-depressant medication in cases of depression and anxiety. In fact, regular exercise has been found to be superior to medication in the long run, with significantly less relapse. Pregnant women may need help in devising an exercise plan they can follow regularly, taking into account their physical limitations and time constraints.
Mindfulness meditation – the practice of mindfulness meditation is to be able to experience and appreciate life in full, in the moment, moment by moment. Contrary to popular misconception it is not meant to make one’s mind blank so they can escape their feelings. Rather, through regular practice of Mindfulness, you can achieve a state of greater calmness, insight and clarity about your life. You can then start to embrace your life, including your challenges, turning them into experiences of growth and strength. Mindfulness meditation has been one of the best evidence supported effective treatment for depression and anxiety (for more information and reviews of studies in this area, you may wish to log on to health.harvard.edu/blog/mindfulness meditation).
Cognitive-Behavioral-Therapy (CBT) – CBT has long been established as a highly effective therapy for both depression and anxiety, whose effects are enduring. For example, see Hollon et al., (2006). Enduring effects for cognitive Behavior therapy in the treatment of depression and anxiety. Annual Review of Psychology. CBT explores the interconnections between thoughts, feelings, behaviors and physiological sensations. Through the understanding of how these interconnections work, one can create change in one area to affect change in another. For example, by changing defeating self-talk or overly anxious self-talk you can achieve a greater sense of calmness and balance. CBT maintains that brain processes, which have been at play for a long time, may still be amenable to change due to the plasticity (i.e., the ability to change) of our brain. The course of CBT is typically between 10-16 weekly sessions. Registered psychologists are knowledgeable and well trained in Cognitive-Behavioral-Therapy.
Interpersonal Psychotherapy (IPT) – IPT addresses interpersonal issues and focuses on the effects of life events on people’s moods. Just like CBT, It is a time-limited therapy, which normally spans 12-16 weeks. IPT has been found to be effective for pregnant and postpartum women with mood disorders (for a review see O’Hara’s review at iptinstitute.com). Some, but not all, psychologists are trained in this therapy.
Emotionally Focused Therapy for Couples – EFT for couples is a short-term (8-20 sessions) structured approach to couples therapy, based on the premises of adult attachment and bonding. The effectiveness of EFT for individuals and couples has been strongly supported by research. Although it may be the pregnant woman who manifests symptoms of depression and anxiety, she may be affected by her relationship with her partner (if she has one) and the partner and the relationship may be affected in return. EFT for couples facilitates the emotional bond between the partners. Many times, an improved, closer and safer relationship with the partner results in significant symptom reduction in the woman. Some psychologists and some Marriage and Family Therapists are trained in EFT for individuals and couples.
To summarize, despite popular belief, pregnant women are significantly vulnerable to mood disorders. Undiagnosed and untreated mood disorders in pregnancy can have serious effects on both mother and baby. Highly effective non-pharmacological treatments are available and should be the first go-to option when possible. Pregnant women who manifest symptoms of depression and/or anxiety should be referred to a mental health professional, such as a Registered Psychologist or a Psychiatrist as soon as possible.
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