National Alliance on Mental Illness
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What is the relationship between depression and pregnancy?
Pregnancy is a profound life event that evokes many emotions. It is important for women with depression who plan to become pregnant—or have found out that they are pregnant—to think about how to best achieve healthy outcomes for both mother and baby. They should have active discussions with their doctors about individual history, medication choices, support strategies, and stress management ideas to help them through this important phase of life.
Often referred to by its clinical name—major depressive disorder (MDD)—depression is a serious mental illness that affects millions of Americans and their families. Depression often consists of multiple well-defined depressive episodes that reoccur throughout one’s lifetime. These depressive episodes—lasting often weeks or months—can include depressed mood, guilt, hopelessness, worthlessness and even suicidality, as well as changes in sleep, appetite, energy and focus. People with depression do not experience the manic episodes associated with bipolar disorder. Depression is often first diagnosed in younger people in their teens and 20s. Therefore, at some time during or after their diagnosis, many women with this illness will either become pregnant or consider becoming pregnant.
Clinical depression is different from the “baby blues” that a large percentage of women experience after delivery. While “baby blues” fade away with time, depression gets worse without proper evaluation and treatment. Depression is common, and scientific studies have shown that up to 10 percent of pregnant women will experience an episode of depression, and up to 15 percent of women will experience a depressive episode in the postpartum period. This is likely due to a number of factors including the hormonal changes associated with pregnancy and disturbed sleep during this time, as well as the emotional, familial, and financial stressors associated with pregnancy and delivery. For many young women, pregnancy and the postpartum period may also be the first time they experience the symptoms of their illness. Some studies suggest that women may be five to ten times as likely to experience a depressive episode during these time periods. While initially debated by researchers, it has become clear over the past decade that women with a prior history of depression are at increased risk of experiencing a depressive episode during or after pregnancy. For women with an established diagnosis of depression, studies suggest that close to one in four women experience recurrent episodes during pregnancy, and approximately one in three women experience episodes during the postpartum period.
Major risk factors for experiencing worsening symptoms of depression may include stopping medication treatment, unexpected pregnancies, and unstable interpersonal relationships. The key is to make decisions with the most complete information available about treatment options, strategies, and the risks and benefits of medications.
What are the complications of depression in pregnancy?Even with treatment, many women with depression will experience more symptoms of their illness during pregnancy. Depressive episodes can place both mother and the developing fetus at risk, primarily due to the fact that women with severe symptoms are less likely to follow up with their doctors and continue treatment as a result of their illness.
Women who are depressed are more likely to experience difficult pregnancies (e.g., pain, worsened sleep or appetite). Those with depression may also be more likely to have premature deliveries, problems with fetal growth and other related complications. However, of greatest concern is the increased risk of maternal suicide both before and after delivery.
In spite of this, many women with depression manage their illness successfully and deliver healthy babies. Each person—and likely each pregnancy for each person—is unique in terms of vulnerability during this period.
What are the risks of stopping treatment during pregnancy?
Medications are typically an important part of treatment to reduce the frequency and intensity of depressive episodes. Yet many of the medications used for depression add risks to the pregnancy. How does one weigh these risks against the risk of lower or no medications on a woman’s own mental health, which is also crucial for the baby? This discussion will center in part on a woman’s other supports and stresses, her history, prior pregnancies, and her ability to recognize the recurrence of symptoms. An open dialogue with one’s doctors is a key piece of the process.
As depression can be a severe illness that is often characterized by multiple, recurring episodes throughout a person’s life, many people will be advised by their psychiatrists to continue treatment with antidepressants even after acute exacerbations, in order to prevent further episodes. Many scientific studies have shown that people with depression who stop treatment with their medications are at increased risk of experiencing another depressive episode. This is particularly the case for people who abruptly stop their medications, as can often happen when a woman unexpectedly discovers that she is pregnant. As previously discussed, many women are at increased risk of experiencing worsening symptoms of depression, both during and after their pregnancies, even when continuing treatment for their illness. Scientific studies have shown that rapidly stopping one’s medications greatly increases this risk, especially during pregnancy and in the postpartum period.
Therefore, it is advised that all women discuss the issue of pregnancy with their psychiatrists. It is useful to discuss the risks of continuing treatment with medication, as well as the risks of recurrence with and without ongoing medication treatment. Psychiatrists can also be helpful in discussing pregnancy planning. Planned pregnancies—as opposed to unplanned pregnancies—may be less likely to increase the risk of symptoms, as they allow the individual to slowly taper off of their medication (e.g., over the course of months) and to watch with their psychiatrists for any changes in symptoms.
How is treatment different for pregnant women with depression?
Whether or not they are considering becoming pregnant, all women with a history of depression should regularly discuss this issue with their doctors. Many women with depression will want to stop treatment with all medications before they become pregnant. A discussion regarding the safety and risks of stopping one’s medications is very important and may end with a plan to slowly taper off one’s medications. Other women will wish to continue being treated with their medications throughout pregnancy in order to avoid the risks of increased symptoms, which can also be harmful to the baby. For these women, many will continue on the same medication—perhaps with decreased doses or with increased monitoring. Still others will change from one medication to another in order to avoid possible risks to the developing fetus.
In general, psychiatrists can be most helpful in explaining the risks and benefits of treatment, but it is the patient’s decision to stop, continue or change medications based on a number of factors. For patients who wish to continue or initiate treatment, many psychiatrists will recommend using the same medications that have been previously successful for the woman, as there is not one specific medication that is necessarily safer in all situations. In fact, none of the medications certified for use by the US-FDA for depression are without risks to the developing fetus (e.g., they are potentially teratogenic). Therefore, women being treated with these medications may have increased screening tests (e.g., ultrasounds and blood tests) throughout their pregnancy, depending on which medications the are using.
The specifics of individual psychiatric medications are largely beyond the scope of this review and should be discussed with one’s psychiatrist, obstetrician, and other treaters. It should be noted that every medical treatment carries a variety of risks, some more serious than others. In general, medications from the SSRI class (selective serotonin reuptake inhibitors) are thought to be first-line medications. These medications are believed to provide the best combination of effective treatment for depression while being safer for the developing fetus than other classes of antidepressant medications. Within this class of medications, some individual medications (e.g., sertraline [Zoloft]) have been shown to be safer than others (e.g., paroxetine [Paxil]). It should be noted that multiple large scientific studies have shown that the children of pregnant women who are treated with antidepressants do not have any serious problems with language, behavior or intelligence.
The specifics of other medications that may be used to treat severe depression—including mood-stabilizers and antipsychotics—are also beyond the scope of this review but are addressed in the section on pregnancy and bipolar disorder. It is also worth noting that electroconvulsive therapy (ECT) has been successfully used for decades in pregnant patients with severe depression. The knowledge base of risks of the medicines increases with time, so it is important to research and discuss the latest findings with one’s doctor to assess medication options.
As with any mental illness, the role of psychotherapy can be critical in alleviating symptoms and decreasing distress. Cognitive behavioral therapy (CBT) has been specifically identified as a first-line treatment for pregnant women with depression and can help to examine and correct the negative thoughts that are part of depression. Behavioral interventions (e.g., eating a healthy diet, maintaining sobriety, exercising regularly, and keeping as regular a sleep schedule as possible) are also very important in preventing and treating depression, both in pregnancy and the postpartum period.
Other important factors to consider in pregnancy and depression
Everyone with depression deserves to be evaluated by a trained and licensed psychiatrist. Many psychiatrists have experience in treating pregnant women; others have less experience and can provide referrals to colleagues with specialized training in this field. Similarly, some obstetricians may refer their patients for consultations to high-risk obstetricians who have additional training in maternal-fetal medicine. In either situation, a woman, her psychiatrist, and her obstetrician should be in regular contact to ensure that care is complete and coordinated.
As the risk of developing a depressive episode may be greatest immediately in the postpartum period, many women at high-risk (e.g., women with a history of multiple episodes or prior episodes in the postpartum period) will often be advised by their psychiatrist to either start or continue treatment with an antidepressant immediately after delivering their child. Scientific studies have shown that this may be the best way to prevent new episodes from occurring in the postpartum period.
Following delivery, new mothers will choose to breast-feed or bottle-feed their babies based on a number of factors. In many cases, the use of psychiatric medications is not necessarily a reason to avoid breast-feeding, as many of these medications are not passed through breast milk in large enough quantities to affect the baby. Most obstetricians and pediatricians recommend breast-feeding, and this should be discussed with one’s individual providers.
Families, friends and others can be most helpful in providing empathic and non-judgmental support of their loved ones and encouraging them to have regular contact with their psychiatrist. With this support and proper medical care, women with depression can increase their chances of having a healthy pregnancy and delivery.
A well-regarded resource is the Massachusetts General Hospital’s Women Center for Mental Health. Updates on treatments and side effects for women, including during pregnancy, can be found at their website.
Reviewed by Jacob L. Freedman, M.D., and Ken Duckworth, M.D., May 2013
Postpartum Education for Parents
Postpartum Support International
Department of Health and Human Services
Pregnancy and Newborn Health Education Center