Obstetrics

May 8, 2006

Walder, 39 years old and from Nottingham, England, felt her mood plummet six months after she conceived. Although she put on a brave face to her colleagues, her family and her doctor, to her private journal she confided thoughts of suicide. "There's this collusion around motherhood and pregnancy," she says. "Everyone makes you believe it's fantastic and wonderful, but for some of us, it's destroyed us."

Contrary to conventional wisdom and medical lore, pregnancy does not necessarily equal happiness, and its hormones do not protect against depression. Doctors estimate that up to 20 percent of women experience symptoms of depression at some point during their pregnancy — about the same as women who are not pregnant. Even as postpartum depression has become TV-pundit fodder, the problem of depression during pregnancy has remained hidden — largely because most people still assume that pregnancy is or should be the realization of every woman's dream. When she was training as a psychiatric resident in the 1980s, Katherine Wisner, now a professor of psychiatry and OB-GYN at the University of Pittsburgh, remembers being told not to worry about pregnant patients who were, in her view, "very ill." Pregnant women, her teachers said, are "psychologically fulfilled."

Finally, pregnancy-linked depression is coming into the open. A series of studies, published this year in medical journals, is looking at all aspects of the problem — with special focus on the effects of antidepressants on the health of pregnant women and newborn babies. These studies have launched, for the first time, a serious debate among doctors over the risks and benefits of treating pregnant women with medication. "There are still unanswered questions" about SSRIs and pregnancy, says Lee Cohen, a psychiatrist at Mass General Hospital in Boston and author of one of the recent studies. "But the doctors — the psychiatrists, the OB's — can't be cavalier, and can't presume that [without treatment] things are going to be fine."

Pregnancy probably doesn't cause depression, per se, but can trigger it in women who may already be genetically predisposed. In a series of experiments published in The New England Journal of Medicine in 1998, psychiatrists Peter Schmidt and David Rubinow found that women who were prone to mild depression associated with premenstrual syndrome felt better only when their hormonal cycles were artificially shut down. They guess that the same is true with pregnancy: massive hormonal changes affect mood, but only in susceptible women. "In some women it may be the dramatic drop in hormones at childbirth that is the trigger," says Rubinow. "In others, it may be the elevated levels at the end of pregnancy."

It's difficult to detect depression in a pregnant woman, doctors say, because so few of them admit they're depressed — and because so many of the symptoms, such as sluggishness and sleeplessness, look alike. But Linda Worley, a psychiatrist at the University of Arkansas, says too few doctors ask pregnant patients about their mood or administer screening tests.

Treating a pregnant woman for depression is a delicate balancing of risks and benefits to mother and fetus. Cohen's study, in The Journal of the American Medical Association, showed that depressed mothers-to-be do better on SSRIs. Women who continued taking medication while pregnant were five times less likely to have a relapse than women who didn't. This is important — and not only for the mother's health. Depressed women are far likelier to smoke, drink and miss doctors' appointments; depressed mothers give birth more often to underweight babies.

At the same time, no one would argue that antidepressants are good for fetuses. In one study, researchers found that newborns whose mothers took Prozac, Paxil or Zoloft in the third trimester had six times the risk of a rare, potentially fatal blood-pressure condition. In another, smaller study, 30 percent of infants whose mothers took SSRIs showed symptoms of neonatal abstinence syndrome, a kind of supercrankiness linked to withdrawal. Most got better within days.

Therapy is a good alternative, especially for women with mild or moderate symptoms. Margaret Spinelli, a psychiatrist at Columbia University, found in a 2003 study that depressed pregnant women had a 60 percent recovery rate with interpersonal psychotherapy, a short-term, focused treatment — about the same rate as with antidepressants. "We just don't have the networks of close-by girlfriends and sisters and neighbors and moms that provide support," adds Pittsburgh's Wisner. Walden didn't get treatment for her depression until after the birth of her daughter two years ago. Now she's a stay-at-home mom trying to wean herself from antidepressants. Sometimes even happy stories have bittersweet endings.

With Joan Raymond and Emily Flynn Vencat

© 2006 Newsweek, Inc.
© 2006 MSNBC.com