Depression

Child Magazine investigates the rate of depression during pregnancy and helps you weigh the risks.

The Pregnancy Blues, p.1

The Pregnancy Blues
Photodisc

Photodisc

I wanted to be pregnant. I'd waited past my 20s and early 30s, waited while I wrote books and carved out my career, and now, at last, I was ready. It was spring. I was 34. The crocuses were pushing their red and yellow skulls up through the last rind of snow, there were pussy willows budding on branches and trees putting on green sleeves, and I was set to go. I bought an ovulation predictor kit. Then I watched, day in, day out, for the sky-blue line to appear, indicating that right this minute, in the warm vault of my body, a ripened egg was dangling. And when the kit turned, when the blue line appeared, I went to my husband and said, "Now."

It was spring. The cats were caterwauling at night, the bees were coming back, and black ants speckled the front steps of our house. I was sure, absolutely sure, I was pregnant. After all, I'd had sex without protection, the egg was ready, the sperm were strong, and it was spring, it was spring, it was spring. Then the blood came. This happened for four months, and with each passing period my desire grew in intensity so that by the time I did conceive I was ecstatic. Completely ecstatic.

I never thought things could go so wrong.

The Pregnancy Blues, p.2

Pregnancy's Double-Edged Sword

Three days after I finally missed my period, high on hope and expectation, I went to a clinic where a phlebotomist tied off my arm and drew merlot-colored blood. It seemed to me my blood looked different; it sparkled and was thicker and richer, smearing the glass sides of the test tube. When the results came back -- it was a yes -- I was not surprised. My husband and I went out to dinner that night, and I said, "I feel so good, so great." He replied, "It must be the hormones," and I thought yes.

We hear stories of women in pregnancy -- women fat and happy, women tanked on the hormones estrogen and progesterone, their hair lustrous, their skin ruddy. We hear how women's sex drive can increase and how they exude an optimistic energy that manifests as nesting. Indeed, says Alexander Vuckovic, M.D., clinical assistant professor of psychiatry at Harvard Medical School in Boston: "Some women feel at their best when they're pregnant. They say it's a time of calm and happiness."

There are physiological reasons why this might be the case. Progesterone, a steroid sex hormone secreted in massive amounts by a woman's body once conception occurs, can cause feelings of calmness, which may be why some women say they feel like they're "floating" through their pregnancy. In fact, progesterone has been investigated for its anti-anxiety properties. At the same time, estrogen, which maintains the endometrium during pregnancy, is present in a pregnant woman's body at a much higher concentration.

But these very same hormones have a sub-story to them, a flip side. While they can increase feelings of well-being, they are also implicated in depression and anxiety. Hormones are powerful psychoactive substances, and because people have different histories and brain chemistries, we respond to them in various ways. "Some women, especially those with a history of mood disorders, are very vulnerable to the hormonal changes of pregnancy," says Adele C. Viguera, M.D., associate director of the perinatal and reproductive psychiatry program at Massachusetts General Hospital in Boston. "Pregnancy can be a time when psychiatric symptoms worsen or return. In rare instances, it can also trigger a depressive episode in women without a history of mood disorders."

The Pregnancy Blues, p.3

Dr. Viguera goes on to say that, by some estimates, 10% to 15% of all women are depressed during their pregnancies. While such depression, also known as "antenatal depression," is much less talked about and subsequently not as well known as postpartum depression, it's no less real. And with depression being increasingly acknowledged and diagnosed today, it's important that we understand how it manifests during pregnancy and what women can do to protect themselves and their babies.

Descent Into Darkness

Having a long history of depression, I'd worried about the postpartum period but decided to take the plunge anyway. As soon as I learned I was expecting, I stopped taking antidepressants out of concern for the fetus. Since then, I've learned that women in my situation should never stop taking their medication without consulting their doctor first.

Like most people, I knew absolutely nothing about antenatal depression. That doesn't surprise Shaila Misri, M.D., director of the reproductive mental health program at BC Women's Hospital Centre and St. Paul's Hospital in Vancouver and author of Pregnancy Blues: What Every Woman Should Know About Depression During Pregnancy, to be published in September. "The symptoms -- fluctuation of mood, feeling tired -- mimic signs of pregnancy," she says. "In addition, this is a time when you're expected to feel happy, so many women can't accept that they may be suffering from depression."

As for me, I was unprepared when, in week six, I was overcome by a feeling of despondency. It wasn't the slow creeping kind of depression I'd experienced in the past. It came crashing. It clicked my world and my self into a separate sphere, one in which everything was grainy and gray, and activities impossible. I lay in bed in a peach-colored room and watched the autumn light move across the ceiling. It was a light saturated with sadness. I stopped sleeping, I stopped eating, and I cried excessively and brooded on my past mistakes -- all common symptoms of antenatal depression. As the baby grew from its primeval dot into an embryo with tail and heart, my own skin shrank and I looked old.

The Pregnancy Blues, p.4

At first I thought the depression was a fleeting mood, but as days went on and I grew sicker and sadder, I saw this was not the case. The depression had weight and substance. It was a stone in the center of my life. My life. I had once liked my life, but now it was a sharp, unwieldy thing I couldn't manage. Time seemed to stretch on and on. Cooking dinner was overwhelming. Mince and grate, scald, steam, boil, and broil -- who could comprehend all those pieces of the recipe? Who could comprehend the intricacies of a zipper with the tab and all its teeth? I stopped getting dressed in the morning. Inside me, the baby's feet and fingers were forming, and her milk teeth were becoming embedded in the gums.

I thought about getting an abortion. I sat on the couch and looked up clinics in the Yellow Pages. It was early enough. But I didn't see how I could abort something I had wanted for so long. Maybe, maybe, I no longer wanted it. My mind went around and around. Was I depressed because I didn't want to have a baby -- or was having a baby, with all its physiological disruptions, making me depressed? This kind of confusion, I later discovered, may be common in women suffering from antenatal depression. The depression distorts your perception of things, so you can't tell what's what.

There are few theories about the cause of postpartum depression; there are even fewer that explain antenatal depression, in part because it hasn't been well studied or even much acknowledged by the medical community until fairly recently. "More investigations into this condition are urgently needed," says Jonathan Evans, M.D., a consultant senior lecturer at the University of Bristol in England and the lead investigator in a large study examining the link between pregnancy and mood in 9,000 British women.

Dr. Evans's research suggests that antenatal depression is more common than postpartum. He found that 12% of pregnant women were depressed at 18 weeks, rising to 13.5% at 32 weeks, then dropping to 9.1% at eight weeks after birth and 8.1% at eight months after birth.

The Pregnancy Blues, p.5

While a woman's hormones play a role in antenatal depression, no one knows exactly how or why. The stress hormone cortisol doubles within the first trimester of pregnancy, and by the third trimester it's three times the normal level. In studies, high cortisol levels are associated with depression. Estrogen, on the other hand, is known to have feel-good qualities. Common sense would have it that the high levels of estrogen should cancel out or otherwise override the negative impact other hormones might have.

But as Dr. Misri explains, it's not the presence or level of hormones that triggers depression during pregnancy. "It's most likely how your brain responds to the changes in hormones that triggers depressive illness," she says. Some women's brains, whether because of genetics or a traumatic event, are exquisitely sensitive to these shifts. That's why women with antenatal depression continue to be at risk in the postpartum period, when hormone levels radically drop.

Deciding For Two

By the tenth week of my pregnancy I was feeling desperate. My ob-gyn referred me to the Perinatal Psychiatry Program at Massachusetts General. There, I was again prescribed Prozac, the medication I'd been on prior to becoming pregnant, and Wellbutrin, also an antidepressant. I remember the psychiatrist handing me a squat white bottle -- a Wellbutrin sample. I remember twisting off the plastic cap, poking through the foil membrane, and smelling the foul sulpherous odor of the medicine. How could I take these pills when an embryo, right this minute, was forming fingernails and a face inside me? What effects would these pills have on the baby, now or later?

Dr. Viguera, the psychiatrist I saw, explained that the benefits of taking antidepressants outweighed the risks in my case. Dr. Misri agrees: "There is no evidence to suggest that the use of antidepressants during the first trimester leads to birth defects." A study released in February, based on an analysis of World Health Organization medical records, found that infants exposed to antidepressants called selective serotonin reuptake inhibitors (SSRIs) in the womb may experience withdrawal symptoms, such as convulsions and irritability. "But even if a baby has withdrawal symptoms -- and not all do -- they are treatable and temporary," says Dr. Misri.

The Pregnancy Blues, p.6

Still, one wonders what will happen to these babies in the long term. Will an adverse condition show up later in life? A recent study from The Carolinas Medical Center in Charlotte, NC, has some sobering news on the issue. Researchers compared 17 babies whose mothers used SSRIs in pregnancy to infants who weren't exposed to these drugs. The study found that babies who were born to women on SSRIs, such as Prozac or Paxil, startled more often, were more tremulous, and exhibited more unusual sleep patterns than their undrugged counterparts, suggesting subtle changes to their nervous systems. And it wasn't clear whether the symptoms were permanent or temporary.

To complicate matters, untreated depression during pregnancy causes subtle and not-so-subtle changes in a fetus's nervous system as well. Women whose appetites and sleep patterns are poor are at greater risk for premature labor. Still other studies have documented that depressed mothers are more likely to deliver low-birth-weight babies.

In addition, recent research from the Avon Longitudinal Study of Parents and Children in England found that women who are stressed or depressed during their pregnancies have children who are more at risk for developing learning and behavioral problems. And a 2004 study conducted at the Touch Research Institutes at the University of Miami School of Medicine revealed that newborns of mothers suffering from depression have higher levels of the stress hormone cortisol and lower levels of dopamine and serotonin (low levels have been linked to depression). Compared to the newborns of women who were not depressed, these infants had a lower heart rate and were more withdrawn.

Back and forth, back and forth my mind went. The American College of Obstetricians and Gynecologists doesn't have an official stance on the matter. It simply advises women to consult with their doctor about what's right for their situation. In the end, however, there may be no good choice because either way there are risks and either way there are unknowns.

Back at home, pills in hand, I took one; I took two. All that day I had heartburn. Then gradually, as hours turned into days, I felt a slow lifting of my mood, like a page being turned or a veil lifted.

The Pregnancy Blues, p.7

A Hopeful Beginning

It's months and years later now. The winter is over. My baby has been born. My daughter weighed seven pounds when they cut her -- cesarean style -- out of my stomach and lifted her high above the drape so I could see her. She had a voracious appetite, a strong sucking reflex, and a mouth so perfect and distinct it looked drawn on. When she sleeps, her eyes dart back and forth, as fast as fish, beneath the clamped lids. She is good-natured and laughs easily. The laugh of a child is a charged and wonderful sound, like something surging up from deep beneath the dirt.

My child's pediatrician says not to worry about her rocky in-utero ride, but of course I do. I worry that years from now she'll become darkly depressed because I did during the first three months of her prenatal life. I worry that terrible tics will surface because of the medication I took during the later months of my pregnancy. At the same time, I appreciate -- like all the women who experience the devastation of depression during pregnancy, a time when you want more than ever to feel joy -- that I did the best I could for myself and my child, who has so far been blessed with excellent health. As for me, I returned to my regular dosage of medication after the birth of my daughter. And the next time, when I was ready to try for my second child, I was prepared.

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Copyright © 2005. Reprinted with permission from the April 2005 issue of Child magazine.

All content here, including advice from doctors and other health professionals, should be considered as opinion only. Always seek the direct advice of your own doctor in connection with any questions or issues you may have regarding your own health or the health of others.

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