A Psychiatrist’s Guide to Treating Depression While Pregnant
Jade’s primary care doctor had been prescribing her Prozac, a commonly used antidepressant medication, for almost a year before two blue lines confirmed that her new onset nausea and fatigue were indeed signs that she was pregnant.
She reflexively stopped her Prozac that same day, both worried and uncertain about the effects the medication might have on her growing fetus. While her primary care doctor had been providing her general medical care for years, she felt it was time to seek out an obstetrician to follow her throughout her first pregnancy. She found a local OBGYN and responsibly made an appointment to confirm the pregnancy and start her perinatal care.
Jade answered “No”, when the nurse at her new obstetrician’s office asked if she had any preexisting health conditions or was on any prescribed medication. She had always been a bit ashamed to carry a mental health diagnosis and no longer wanted to claim it as a part of her identity. And anyway, she reasoned, she had been feeling well despite not taking her Prozac in over two weeks by this point, so technically it was true that she was not on any medication. The OBGYN asked her the typical perinatal depression screening questions, and Jade gladly answered that she had not been having any of the queried symptoms of late.
Weeks went by and slowly Jade’s energy and motivation waned. It was becoming increasingly difficult to get out of bed for work and her once tidy apartment was beginning to look a bit chaotic. She reasoned that her poor appetite was because of her morning sickness. And her difficulty concentrating at work must have been because of the “pregnancy brain” phenomenon she had heard about. Her husband noted that she often seemed sad and irritable these days, and she detected disappointment in his eyes as he wondered why she was not more upbeat during such a happy time in their lives. He half-accepted her retort that it was “just pregnancy hormones,” though quietly worried that she was starting to act as she had a year ago when she was first diagnosed with depression. She eventually abandoned her favorite hobbies of photography and baking, and found that even around friends, she felt detached and unable to enjoy their company as she once had. One day while driving, Jade wondered what it would be like to run her car off the road and into one of the huge trees that lined her route to work. The thought scared her, and at her follow up with her OBGYN she admitted tearfully that she was indeed depressed. She told the story of her being previously diagnosed with depression and the Prozac that she had taken until she learned of her pregnancy. Her OBGYN reassured her, and Jade accepted a referral to a local psychiatrist for further evaluation.
Jade is like many women I see in clinic, who are either referred by another doctor or come in of their own accord after realizing their mental health is spiraling out of control while pregnant. Many have a history of depression or other mental illness, and have stopped their antidepressant without talking to their doctor first, due to concerns about how their baby may be affected. Others do not have a mental health history but start to show signs of depression after they become pregnant. Often when they see me, women are quite symptomatic and wanting to know what they can do to get their depression under control, while still keeping their baby’s safety in mind. Here is what Jade and other women struggling with depression while pregnant should know:
1. It’s okay.
There is an immense amount of pressure on a mother-to-be to feel blissfully happy and grateful, coming from both well-meaning associates and society at large. Social media is rife with photos of beaming women in their second or third trimester, dressed in carefully chosen maternity gowns, gliding through fields of daisies, and floating on clouds of joy.
Friends and family in their own excitement can send the message too, that all is right in the world now that a baby is on the way. And while pregnancy can absolutely be a time of great joy and excitement for some women, others are suffering inside. According to a 2016 article in the Archives of Women’s Mental Health, the prevalence of major depression among pregnant women in the US is as high as 27%, and the rates are even higher for less severe forms of the disease.
The take-home point here is that depression in pregnancy happens. A lot. There are a host of hormonal, inflammatory, and sleep-related changes that put a pregnant woman at increased risk for new onset depression. Tell your doctor about any past diagnosis of mental health conditions and any medications you have taken in the past.
Remember that having depression at any point, including pregnancy, does not mean anything bad about you as a person. It just means that you, like many other women, need a little help and support during this time (who doesn’t?), and that’s okay.
2. Depression is more than feeling sad, and is often overlooked in pregnant women.
Sadness is a normal emotion and an inevitable part of the human experience. We all periodically feel sad in response to our thoughts about situations in our lives that we perceive as negative or difficult.
On the other hand, Major Depressive Disorder (simply referred to as depression in this article) is a serious health condition, the number one cause of disability worldwide, and has potentially lethal consequences, including suicide.
A diagnosis of depression is typically made by a psychiatrist or other mental health professional, though many people are diagnosed by their primary care doctors as well. The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (abbreviated DSM-5) lists the criteria for all currently recognized psychiatric disorders and defines Major Depressive Disorder as having 5 or more of the following symptoms over the same 2 week period, one of which must be depressed mood lasting most or all of the day, or loss of interest or pleasure in almost all activities. The remaining criteria are: significant weight change or significant change in appetite, sleeping much more or less than usual, moving noticeably slower or faster than usual, fatigue or loss of energy, excessive feelings of guilt or worthlessness, diminished ability to think or concentrate, and recurrent thoughts of death or suicide. These symptoms must cause significant distress or difficulty functioning in one’s life, and not be attributable to another underlying medical or psychiatric illness or drug/alcohol use.
Depression is easily overlooked in pregnant women because many of the symptoms overlap with typical experiences of pregnancy, in particular the changes in appetite, sleep, energy, and even concentration. If you think you may be depressed, go and talk right away with your doctor for a thorough evaluation, and treatment if needed.
If you are already on an antidepressant prior to becoming pregnant, I cannot stress this enough: do not stop your medication before talking with your doctor.
Stopping your antidepressant can cause a relapse of depression symptoms which can be particularly challenging to manage in pregnancy. Also, certain antidepressants may cause uncomfortable physical symptoms of discontinuation if stopped abruptly. Foregoing treatment of depression in pregnancy is linked to poor outcomes for both mother and baby, including increased risk of postpartum depression, poor maternal self care, higher likelihood of maternal engagement in high-risk health behaviors (like smoking, alcohol and illicit substance use), impaired mother-baby bonding, increased health complications for mother and child, maternal suicide and infanticide.
3. There are many options for treating depression in pregnancy, and yes, medication is one of them.
For mild to moderate depression in pregnancy, there are two types of psychotherapy (also known as talk therapy) which are considered to be first line treatments: Cognitive Behavioral Therapy, and Interpersonal Therapy. Both can be delivered by a psychiatrist, psychologist, or therapist trained in these modalities. Therapy eliminates the risk of antidepressant effects on mother or baby, and may be a good option for women who have access to a skilled therapist, and the time and motivation required to maximize psychotherapy’s usefulness. Some other non-medication options that have limited data to support their efficacy for perinatal depression include: light therapy, exercise, vitamin D, omega-3 fatty acids, folic acid and supportive psychotherapy. Women who opt to use psychotherapy or any of these alternative treatment options, should also still have access to a physician (psychiatrist, OBGYN, or general practitioner) so that medication can be prescribed if these measures do not adequately control their depressive symptoms.
For severe symptoms of depression in pregnancy, in particular suicidal thoughts, significantly impaired ability to function, or when there are other serious mental health symptoms such as hallucinations occurring concomittantly, then psychiatric medication is first-line treatment. Antidepressants should also be considered in less severe cases when obtaining psychotherapy is not an option.
Many scientific studies have been done evaluating the safety of antidepressants in pregnancy. The most studied class of antidepressants used in pregnancy are the selective serotonin reuptake inhibitors, or SSRI’s which include Prozac, Celexa, Lexapro, Zoloft, Paxil and Luvox. Results vary among the studies, but some have found that antidepressant use in pregnancy may be associated with small increases in risk of miscarriage, low APGAR scores and higher rates of NICU stays, persistent pulmonary hypertension of the newborn, and heart anomalies. These risks are small when compared to women who do not take antidepressants, but you should still be aware of them and talk to your doctor about your personal risks. It’s important to note that most experts agree the risks associated with not treating depression during pregnancy, outweigh the risk of taking antidepressants.
If you choose to take an antidepressant during pregnancy, know that Zoloft (generic name, Sertraline) is the best studied and considered by most experts to be one of the safest options in pregnancy. It is also considered to be compatible with breastfeeding, as rates of transmission to baby through breast milk are relatively low. If you have never been previously on an antidepressant to which you had a robust positive response, then your doctor may recommend Sertraline, though there are many other options available too. If you have a history of taking an antidepressant in the past to which you responded well, then the general recommendation is that your doctor restart the antidepressant that worked well for you before, if that medication is safe in pregnancy. Non-SSRI antidepressants such as Wellbutrin, Remeron, Effexor, and Cymbalta are less well-studied but in many cases can still be used safely. Monoamine oxidase inhibitor antidepressants (MAO-I’s) including Parnate, Nardil, and others in this class, are generally avoided in pregnancy.
4. The decision on the best treatment option is yours, and no one else’s.
It is common for mothers-to-be to receive unsolicited advice both from the experienced and wiser, as well as the clueless and ill-informed. Talk to your personal doctor about the risks, benefits and options for treating depression while pregnant. And then remember, that the final choice for what is best for you and your baby, is up to you.
You've got this,
“Estimated prevalence of antenatal depression in the US population”. Archives of Women’s Mental Health, 19, 395-400 (2016); June M. Ashley, Bridgette D Harper, Clarissa J Arms-Chavez, Steven G LoBello).
“Between a rock-a-bye and a hard place: mood disorders during the peripartum period.” Michael Thomson and Verinder Sharma. CNS Spectrums (2017), 22, 52-63. Cambridge University Press 2018
Disclaimer: This article does not constitute medical advice and does not establish a doctor-physician relationship. Always seek specific advice and treatment from your own personal doctor.