When I began looking into prenatal depression, it appeared to be an underdiscussed yet potentially devastating part of pregnancy for millions of women. This hunch was hammered home by the results of the survey that I posted along with the first and second parts of this series. At the time of this writing, more than 1,200 of you were gracious and brave enough to answer the survey. The survey was for women who had experienced prenatal depression and their partners, and the vast majority of respondents—more than 85 percent—said they felt guilty about their prenatal blues, and less than a third of survey-takers said they were comfortable talking about their depression with family and friends. Over and over again women used the same words to describe why they kept their feelings to themselves: They were embarrassed, they felt no one could relate, they feared being judged or misunderstood.
What stood out most among the survey responses was that the emotional care pregnant women receive is profoundly inadequate: Only 35 percent of respondents had a doctor, midwife, or doula even ask them about how they were feeling. Even when women told their doctors they were depressed, 32 percent of the caretakers were outright dismissive of their patients’ moods. One woman’s doctor told her to “stop watching too [many] soap operas.” Furthermore, awareness of prenatal depression among mental health professionals is minimal. Only 14 percent of women who were seeing a psychologist, social worker, or psychiatrist when they became pregnant were told to look out for prenatal depression.
However, when you look at the familial response and treatment options for women who experienced prenatal depression, one thing seems clear (if perhaps not surprising): Women who had the support of their partners, families, friends, and medical professionals had the best outcomes.
Just as other studies have shown, our respondents reported that their prenatal depression had a variety of triggers. It hit readers from all across the economic spectrum, though women with difficult environmental circumstances described that as an exacerbating factor. One woman who described her financial situation as precarious said that she and her husband got in a bad car accident when she was 11 weeks pregnant. Their injuries resulted in a layoff (for him) and a demotion (for her). “I've always worried about money, and now we had a baby on the way, one unemployed/unemployable parent, and a demotion. It was too much, and I felt we wouldn't be able to provide for our son,” she says. She was so beside herself that she considered abortion.
Even more heartbreaking were the women who had unsupportive or downright abusive partners and peers. A few women described their significant others as having affairs, turning to drugs, or being out-and-out louts while they were in the depths of clinical, pregnancy-related depression—which of course made things worse. One woman’s husband advised her “that if anything was wrong with the baby at birth, it would be because of my depression.” And even for women whose husbands were supportive and loving, untreated prenatal depression took a toll on the marital relationship. “It was a brutal, brutal, dark time leavened by some very wonderful moments and then a very perfect son,” a husband wrote to me. “But we're still coping with and trying to overcome the distance that grew between us during that time.” Research shows that about 10 percent of men get depressed during and after their partners’ pregnancies, and they have a much higher rate of depression when the mother is also depressed.
Regardless of life circumstances, for many of the respondents, hormones seemed to play a critical role in prenatal depression. As noted earlier in this series, there is a correlation between a bad reaction to birth control pills and the incidence of prenatal depression. Nearly half of survey-takers said they had had an adverse reaction to the pills, with symptoms ranging from excessive moodiness to low libido. Several readers also mentioned previously diagnosed PMDD—premenstrual dysphoric disorder, a hormone-related malady that can involve depression, anger, and anxiety before your period.
Two-thirds of respondents had a history of depression before they conceived, and about 39 percent of readers were on antidepressants. Of those on medication, a whopping 70 percent went off because they were pregnant—either when they started trying to conceive or just after conception. Most of them went off for the same reasons I did: They wanted the pregnancy to be pure, and they weren’t aware of the risks of relapse. Since even many doctors are not up to date on the latest research about pregnancy and antidepressants, understandably many women went off their meds based on misinformation. “I believed that the pregnancy hormones would carry me through without major depressive symptoms,” one respondent wrote.
The quality of treatment for prenatal depression was all over the place. In fact, the majority of respondents first diagnosed themselves with depression rather having a doctor identify it and point it out. The first step in treatment was getting a doctor to take their moods seriously—as noted above, not always the easiest task. Doctors who didn’t really acknowledge the level of stress their patients were under told these pregnant women to do things like take iron supplements or count their blessings, or they said that the women's emotions were “just hormones” and would resolve themselves. “They gave me fish oil and told me not to stress because it would have bad effects on the baby and may cause preterm labor. This made my panic worse,” said a mother of one whose depression hit in the second trimester.
Even when doctors were understanding about their patients’ condition, the treatment options they offered varied widely. There was no standard care for either assessing or treating depressed pregnant women, and some doctors had extreme biases against prescribing antidepressants. Often, even when a woman was getting the best care—input from mental health professionals and an obstetrical team—the advice would be conflicting. This respondent’s experience was typical:
[My OB] wanted my psychiatrist to … aggressively medicate me for my increasing depression. My psychiatrist was deeply resistant of adding additional meds, and wanted me to "push through" the 18 or so weeks left in pregnancy. My ob/gyn over about a month encouraged me to get second opinions and pursue alternative therapies, both of which I reluctantly did. These included: Increased exercise, acupuncture and second opinions (and third and fourth).
It’s tempting to feel completely discouraged about the current state of prenatal care while reading the stories our survey respondents told us. However, there is some good news and some wonderful resources that our readers recommended. One positive theme from the survey is that treatment and awareness have both improved over the years. The oldest respondents had nearly uniformly terrible experiences. (In response to the question, “What treatment options were you given once your prenatal depression was diagnosed?”, a woman in her late 60s or early 70s wrote, “You’re kidding, right?”) But at least some of the younger respondents were getting great care.
Furthermore, women who did get adequate treatment and support from their inner circle often came through the experience of prenatal depression feeling stronger than they did before. For other women, having prenatal depression diagnosed during their first pregnancy made a second pregnancy possible and even joyful. “My husband was incredible,” one woman wrote. “To this day, he says he wouldn't change a thing about the pregnancy because it brought us closer together.”
There are two online resources that were mentioned over and over again as places where women with prenatal depression could dig into the scientific literature and get the help they need. One is a Canadian website affiliated with the University of Toronto called Motherisk. They have a toll-free helpline where women can get one-on-one counseling that is accessible from the United States. The other oft-cited resource is the Massachusetts General Hospital Center for Women’s Mental Health.
Ultimately, what may be the most helpful is a measure of uniformity in the care that prenatally depressed women are receiving. This really hit home for me when reading Atul Gawande’s New Yorker piece from earlier this month on how hospitals can become more efficient. Gawande mentions an orthopedic surgeon who has standardized the way knee replacement surgery is performed at his hospital. One of the key points Gawande makes is that the care was all coordinated, from the orthopedists and nurses down to physical therapists and radiologists: “They were a team, and that was no small matter.”
The women in my survey who seemed to be getting superlative care were women whose obstetrical offices also employed a mental health professional as part of their practice. That way, all the caretakers could be on the same page. And considering that rates of prenatal and postpartum depression are both around 15 percent, having mental health resources on site could save suffering patients from having to get a referral or expend a lot of effort to get the help they need. One thing was clear from the experiences of our best-cared-for respondents: Depression is such a common part of the pregnancy experience that looking out for it—and addressing it—should become a more seamless part of the care women are receiving.