Anxiety and Depression During Pregnancy: Symptoms, Risk Factors, and How to Cope

Research has shown that approximately 16% or more of expecting parents experience clinical anxiety or depression at some point during pregnancy. Yet some studies indicate that fewer than 20% of them seek treatment, and that treatment is often inadequate, says Healy Smith, M.D., a reproductive psychiatrist at the Women's Mental Health Clinic at New York-Presbyterian Hospital in New York City.

"The myth that pregnant women must be happy is still really prevalent," Dr. Smith explains. "Because of that, treatment providers may be less likely to inquire into a woman's mental state, and a woman might feel ashamed to bring it up." This means that many expecting parents may be dealing with anxiety and/or depression without getting the support and help they need.

The American Academy of Pediatrics (AAP) released a policy statement in December 2018 stating that doctors should screen for depression during pregnancy in order to protect the baby's health. "When we are able to help a mother deal with her mental health, we are essentially reaching the whole family," says author Dr. Marian Earls. The statement also says that pregnant people should be screened for depression after the baby’s birth—specifically when they reach 1, 2, 4, and 6 months old.

If your screening shows you have anxiety or depression during pregnancy, don't worry—there are safe ways to treat these common conditions.

Symptoms of Depression During Pregnancy

It can be tricky to diagnose mood disorders during pregnancy because "some of the symptoms can overlap with symptoms of pregnancy, such as changes in appetite, energy levels, concentration, or sleep," Dr. Smith says. "It's also normal to have some degree of worry over the health of the pregnancy." But if you experience persistent symptoms of depression and/or anxiety, especially if you're unable to function normally, get help.

Symptoms of depression during pregnancy include:

• A sense of worthlessness
• Being in a depressed mood most of the time for at least two weeks. You may feel sad, hopeless, “empty,” and generally discontented
• Changes in appetite
• Decreased interest in the world around you
  
• Feeling guilty
• Getting too much or not enough sleep
• Low energy
  
• No longer enjoying the things you used to enjoy
• Poor concentration
• Thoughts of suicide
  

Symptoms of Anxiety During Pregnancy

The symptoms of anxiety during pregnancy vary by type of disorder, including generalized anxiety disorder, obsessive-compulsive order, and panic disorder.

Generalized Anxiety Disorder Symptoms

• Disrupted sleep patterns
• Excessive worry that's difficult to control
• Fatigue
  
• Feeling restless inside
  
• Irritability
• Poor concentration
• Tension/muscle aches
  

Obsessive-Compulsive Disorder Symptoms

• Compulsions to relieve those thoughts through repetitive thoughts or behaviors
• Recurrent, persistent, intrusive thoughts
  

Panic Disorder Symptoms

• Persistent fear of having a panic attack
• Recurrent panic attacks
  

Risk Factors for Anxiety and Depression During Pregnancy

Doctors once thought that all of those hormones rushing around a pregnant person's body during pregnancy would shield them from depression. We now know that for some parents-to-be, the opposite is true. But while experts agree that hormones play a role in depression, the exact mechanisms are unknown.

"It may be triggered by any number of physiologic or life stressors," says Sheila Marcus, M.D., director of the Women's Depression Program at the University of Michigan Depression Center in the department of psychiatry. "In women with a genetic predisposition to depression, the hormone changes may be one of these stressors," Dr. Marcus says

Anyone can experience anxiety and depression during pregnancy, but people with these risk factors are especially susceptible:

• A personal or family history of a mood disorder, such as depression or anxiety
• A history of premenstrual dysphoric disorder (PMDD)
• Being a young parent (under the age of 20)
• Being divorced, widowed, or separated
  
• Experiencing personal relationship or marital conflict
• Feeling ambivalent about being pregnant
  
• Having a low income
• Having gone through traumatic or stressful events in the past year
  
• Having poor social support
• Having more than three children
• Living alone
• Pregnancy complications
  

Possible Complications of Untreated Anxiety and Depression

It's important to get treatment for anxiety and depression as these conditions can lead to complications. "There are well documented, but often overlooked, consequences of untreated anxiety and depression during pregnancy for the fetus and the mother," Dr. Smith says.

Risks to developing babies whose expecting parent has untreated prenatal mental health issues include:

• Low APGAR score (which rates a newborn's health after delivery)
  
• Low birthweight
• Poor adaptation outside the womb, including respiratory distress and jitteriness
• Premature birth(before 37 weeks)

Risks to the expecting parent include:

• Having a C-section
  
• Impaired attachment to the baby
• Not taking good care of their physical health
• Postpartum depression or anxiety
  
• Preeclampsia
• Pregnancy termination
• Preterm labor
• Suicide
  
• Use of substances such as alcohol or drugs
  

Treatment of Anxiety and Depression During Pregnancy

Experts agree that depression and anxiety require medical attention. But deciding how to treat them in pregnancy is a real challenge, particularly in more severe cases. Your medical providers will come up with the best approach for your care. We outlined some medicinal and non-medicinal treatment options here.

Non-Medicinal Approaches

The following treatments have been shown to help pregnant people with mild to moderate depression.

• Psychotherapy, such as cognitive behavioral therapy (CBT), in which a skilled therapist teaches new approaches to managing thoughts and emotions
• Omega-3 essential fatty acids, which are found in foods such as oily fish and walnuts, can act as a natural mood-booster
• Light therapy, in which patients are exposed to artificial sunlight at specific times of the day to help relieve depression symptoms
• Acupuncture, a Chinese practice that (in this case) involves placing tiny needles into areas of the body thought to influence mood

Antidepressants and Anti-Anxiety Medication

Medication is usually the most effective method for treating anxiety and depression. "But many doctors and mothers-to-be are afraid of the medications," says Gideon Koren, M.D,. former director of the Motherisk program at the Hospital for Sick Children in Toronto. The main concern is that the majority of drugs have never been tested on pregnant people, so doctors are unsure of their effects on unborn babies.

The most commonly prescribed options include Wellbutrin and selective serotonin reuptake inhibitors (SSRIs) such as Zoloft, Prozac, Lexapro, and Celexa. Some studies show potential links to preterm birth and low birth weight (similar to rates of pregnant people with untreated depression), neurodevelopment (and possibly with autism spectrum disorder), and short-term effects like fussiness and poor feedings. You and your doctor need to weigh the benefits of antidepressants against the risks.

If you're currently taking medication for depression or anxiety, consult your psychiatrist before you stop. One study found that "women who discontinued an antidepressant around conception had a 68 percent chance of recurrence of depression during pregnancy, compared to 26 percent for those women who continued their medication," says Stephanie Ho, M.D., a reproductive psychiatrist in private practice in New York City. Of those that relapsed, the majority had to restart their medication during pregnancy.

What’s more, a February 2019 study reported that the prenatal vitamin EnBrace HR may effectively prevent depression during pregnancy. The results, published in Annals of Clinical Psychiatry, found that pregnant women taking EnBrace HR had a 40% lower rate of depression than those who completely discounted their antidepressant.

“In this study, EnBrace HR was investigated for depressive relapse prevention and for acute treatment of major depressive disorder (MDD) in women planning pregnancy or during pregnancy,” according to the report. “The efficacy observed in this study confirms that Rx EnBrace HR, an all-natural, nutritional pre- and post-natal vitamin with methylfolate is an effective, safe option for treating and preventing depression in pregnancy and was well tolerated by patients.” EnBrace HR has no side effects, and it also provides protection against conditions like spina bifida, congenital disorders, neural tube defects, and miscarriage.

A 2021 review study of the possible benefits of taking various nutritional supplements or consuming certain foods (often called nutraceuticals) for depression treatment and prevention concluded that "omega 3 fatty acids, vitamin D, SAMe and methylfolate are the nutraceuticals with most effects proven." However, the study authors says, "Nutraceuticals could be a potential support and adjunctive therapy in patients with MDD, but always combined with accepted therapies, as the benefits then could be greater."

Finding Support and Specialists

If you're pregnant and you're having depression or anxiety symptoms, talk to your OB-GYN or midwife. They should be able to treat you directly, or connect you with the appropriate mental health care provider. These organizations can also offer confidential help:

Postpartum Support International

Postpartum Support International will connect you directly to a local coordinator who can help you find local resources, offer support, and give you tips on managing mood and anxiety disorders during and after pregnancy (www.postpartum.net).

The MGH Center for Women's Mental Health

The MGH Center for Women's Mental Health offers credible information on the risks of untreated depression during pregnancy, as well as evaluation and treatment options (www.womensmentalhealth.org).