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I had prenatal depression when I was expecting my first daughter in 2012. It’s not something I think about often, seven years after the worst of my symptoms, though I occasionally have a flash of sweaty, humiliating memory. Like when I’m on the A train and I pass Canal Street — the subway stop I used for work during my darkest days — I’m reminded that I was so anxious it took me hours to get on the train because I was irrationally afraid of a terrorist attack or of fainting onto the third rail.
Around that time, I wrote a series on prenatal depression for Slate in which I discussed the difficult decision to go back on antidepressants at the end of my first trimester. In that moment, I hadn’t realized that I’d had two major risk factors for depression during my pregnancy: my previous episodes of clinical depression, and the fact that I went off antidepressants to conceive. When I had my second child in 2016, I decided to stay on my daily dose of 10 milligrams of Prozac throughout that pregnancy and did not relapse.
If you have severe anxiety or depression while you are pregnant, the decision to medicate isn’t a question of risks versus benefits, said Dr. Pooja Lakshmin, a clinical assistant professor of psychiatry at the George Washington University School of Medicine. “It’s a risk-risk question, because either side you fall on comes with some risk,” Dr. Lakshmin said. “Untreated depression and anxiety has profound effects on Mom, the baby and the whole family.” Among the risks of untreated prenatal depression are pre-term birth and low birth weight, while among the risks of using S.S.R.I.s during pregnancy are also … pre-term birth and low birth weight. (It’s also worth noting that most studies on pregnant women and medication are observational, which are not the highest quality studies.)
Though both of my children were born healthy and hearty, and have no lasting issues, I still feel embarrassed by what I went through, as if needing psychiatric help during pregnancy is a black mark on my maternal report card. But today is World Maternal Mental Health Day, so it makes sense to talk frankly about what I experienced. As many as one in five women will experience perinatal mood and anxiety disorders; including prenatal and postpartum anxiety, and depression and psychosis. About 8 percent of American women take antidepressants during pregnancy.
I asked Dr. Lakshmin — as well as Dr. Samantha Meltzer-Brody, the founder and director of the Univeristy of North Carolina Perinatal Psychiatry Program and co-author of a 2017 study published in The Lancet Psychiatry which identified five different subtypes of perinatal depression — about how women can get the best mental health care during their pregnancies and afterward. Here are their tips.
Know the risk factors for prenatal depression. A history of mental illness is not the only risk factor for prenatal depression, said Dr. Meltzer-Brody. Other risk factors include a history of adverse life events like sexual abuse, a lack of social support, and living in poverty. There’s also a hormonal component, she said: “There’s evidence that hormone sensitivity in women during the reproductive life cycle makes some women vulnerable” to mood disorders during any hormone shifts. So women who have a history of premenstrual dysphoric disorder (severe depression or anxiety the week before your period) or who react badly to hormonal birth control may be more likely to have perinatal mood disorders.
If you have a history of mental illness, start planning before you conceive. This may not be possible, as about 45 percent of American pregnancies are unplanned. But if you know you want to get pregnant, start working with a psychiatrist you trust, said Dr. Lakshmin — you want someone who will support you and your decisions around medication during pregnancy. One thing to consider is how severe your illness is. If you have been suicidal or hospitalized while off medication, you may not be a good candidate for going off meds.
If you’re going to go off medication to conceive, do so about two to three months before you start trying, said Dr. Lakshmin. That way you have time to see how you feel off meds before the hormonal onslaught of pregnancy. And never stop your medication cold turkey — you should taper your medication under the care of a psychiatrist.
Have other supports in place, Dr. Lakshmin recommended, knowing that the medication part of your treatment will no longer be there. Seeing a therapist more frequently, practicing prenatal yoga or having extra support from friends and family can help.
If you have persistent symptoms of anxiety and depression during your pregnancy, get help. Untreated anxiety and depression during pregnancy doesn’t just magically resolve when you give birth, said Dr. Meltzer-Brody — it’s a major risk factor for postpartum depression. Prenatal depression during the first trimester is often missed, because the nausea, vomiting and fatigue may make women who are not clinically depressed feel down, Dr. Meltzer-Brody said.
If you are down, moody or anxious for two weeks without relief during any trimester, and it’s a marked change from your baseline, check in with a medical professional, said Dr. Meltzer-Brody. For mild or moderate anxiety and depression during pregnancy, evidence-based psychotherapy is recommended. For moderate or severe anxiety or depression, medication may be needed, said Dr. Meltzer-Brody. If you feel suicidal or have thoughts of self-harm, do not wait two weeks — get medical help immediately. You can call the National Suicide Prevention Lifeline at 1-800-273-8255.
If you have trouble finding a perinatal psychiatrist or if your insurance doesn’t cover visits, you can look for programs like Mothers and Babies or Postpartum Support International, which help women with prenatal depression. You can also find volunteers who provide support to women in every state here.
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Want More on Perinatal Depression?
In February, The New York Times’ Pam Belluck wrote about efforts to bring counseling to women who may be at risk for prenatal and postpartum depression. In 2014, Belluck wrote a pair of articles about perinatal depression and anxiety called “Mother’s Mind,” which are a must-read on the topic.
In March, Belluck also reported on brexanolone, the first drug approved by the Food and Drug Administration that is specifically used to treat postpartum depression. (Dr. Meltzer-Brody worked on the clinical trials for the drug.) Brexanolone is given by infusion and works much more rapidly than other antidepressant medication, which can take weeks to kick in, though it comes with a $34,000 price tag.
When I was experiencing prenatal depression, the one book that made me feel less alone was “Love Works Like This” by Lauren Slater, a psychologist and writer. Slater’s book combines her personal experience and professional expertise. The one fact I still quote (and quoted in my Slate series) is that during your first trimester, you are getting about 400 birth control pills worth of progesterone a day. No wonder I felt like I was losing my dang mind!
Our toddler hates wearing sunscreen during the day, but loves putting on lotion at night before bed. We started calling sunscreen “outside lotion” and it changed everything — now she’s eager for sun protection.
— Jessica Smedley, Melbourne, Australia
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